After-School Club Application

Emergency Medical Treatment
I Do/Do Not (Choose below) give ADEC staff permission to transport my child to the closest hospital for treatment in case of accidents. I understand every attempt will be made to notify me before my child is transported.*
- Do
- Do Not
Signature*
By typing your name in the box below, you have read the Emergency Medical Treatment statement and make firm your decision.
Date Signed*
Month
Day
Year
TO ANY DOCTOR OR HOSPITAL:
I hereby authorize the release of my child's pertinent medical information to the appropriate professional staff. I give permission to the physician or hospital to secure treatment for him/her and to order medications, injections, anesthesia, or surgery for my child, as named above, in case of emergency. The signature below constitutes authorization to perform any necessary treatment for my child during while under the care of ADEC.
Signature*
By typing your name in the box below, you have read the above statement and make firm your decision.
Date Signed*
Month
Day
Year
Health Insurance Information
Policy #:*
Parent/Guardian Name:*
Company Name:*
Group #:*
Date*
Month
Day
Year

Photo/Video/Media Release
I Do/Do Not (choose one) give ADEC permission to have my child appear in any media coverage/ADEC publicity approved by the ADEC After School Program.*
- Do
- Do Not
Signature*
By typing your name in the box below, you have read the Photo/Video/Media Release statement and make firm your decision.
Date Signed*
Month
Day
Year
Travel Authorization
I Do/Do Not (Choose below) give permission for my child to leave the ADEC After School Program for trips in a car, van or on public transportation for field trips and community outings. I understand I will be notified and informed of any field trips and outings beforehand or as soon as possible.*
Restrictions of traveling for field trips: Each child will be secured in a seat belt while riding in a vehicle with the ADEC After School Program.
- Do
- Do Not
Are there any other travel restrictions regarding your child? List below:
Signature*
By typing your name in the box below, you have read the Travel Authorization statement, filled in any additional restrictions you would like to apply to your child and make firm your decision.
Date Signed*
Month
Day
Year
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Child Information