WRAP Student Registration Form

Long Beach WRAP After-School Program 2017-2018 Student Registration Form

School/Site: Teacher: School Year: 2017 - 2018

Student’s Name: Grade:

Male /

Female Parent/Guardian Name:

Address: City: Zip:

Home Phone #: Cell Phone #: Other Phone #: Additional Emergency Contact Information (In the event that the parent/guardian is not available) Only the people listed on this card will be permitted to pick up my child. I have contacted the following individuals and they agree to assume responsibility for my child.

Doctor’s Name: Phone:

Is your child allergic to any foods? Yes / No If yes, please list: Is your child allergic to bee stings? Yes / No If yes, does student carry Epi-Pen?: Yes / No Does your child have asthma? Yes / No If yes, does student carry an inhaler?: Yes / No Is your child allergic to any medications? Yes /No If yes, please list: Does your child take medication during the school day? Yes / No If yes, please list: Does your child have any other special needs? Yes / No If yes, please list:

Parent/Guardian Signature: Date: Release for Emergency Treatment In case of emergency and I cannot be reached, I do authorize, pursuant to the provisions of Section 25.8 of the California Code of Civil Procedure, any and all attention as may be deemed necessary by the physician/medical advisor in charge. I also realize that local police and paramedics may be called in certain circumstances in order to ensure emergency treatment. I understand and abide by the stated terms of this release.

Parent/Guardian Signature: Date: Release for Permission to Participate in the Evaluative Survey I agree / do not agree to allow my student to participate in any evaluative survey related to the LB WRAP program. Release for Permission to Photo, Video and Sound Record I hereby release, discharge, and agree to hold harmless the Long Beach Unified School District and those acting under its permission from any liability to the extent permitted by law, for the preparation, distribution and use of photos, videos and/or sound recordings.

Parent/Guardian Signature: Date:

Rev. 5/6/13 208