ALFAL Youth Enrichment Center

Student Enrollment

* First Name
* Last Name
* Gender
* Date of Birth
* Age
* Child's Social Security Number
School ID
* School Attending
* Address
* City
* State
* Zip Code
* Allergies
Medication
Special Medical Needs
Pertinent Medical History Information
Any other information critical to the child’s well-being; or pertinent information regarding growth and development of the child:

Primary Parent or Guardian

* Relationship to Child
* Parent Name
* Address
* City
* State
* Zip Code
* E-mail Address
* Primary Phone: Area Code and Phone NumberFormat: 555-555-5555
Home:  Area Code and Phone NumberFormat: 555-555-5555
Work:  Area Code and Phone NumberFormat: 555-555-5555
Work Hours

Secondary Parent or Guardian

Relationship to Child
Parent Name
Address
City
State
Zip Code
Email Address
Mobile: Area Code and Phone NumberFormat: 555-555-5555
Home:  Area Code and Phone NumberFormat: 555-555-5555
Work:  Area Code and Phone NumberFormat: 555-555-5555
Work Hours

PERMISSION FOR MEDICAL TREATMENT

I understand that every effort will be made to contact me in the event of any emergency requiring medical attention for my child. However, if I cannot be reached, I hereby authorize ALFAL Youth Enrichment Center to transport my child to the nearest hospital or medical facility and to secure my child the necessary medical treatments.  I understand the employees are trained in the basics of First Aid/CPR and I authorize them to give my child First Aid and or CPR if necessary.

* Child's First and Last Name
* Age
* Grade
* School
* Physician's Name
* Physician's Phone NumberFormat: 555-555-5555
Insurance Provider
Policy Number
Please list any allergies, medical conditions, physical limitations, and regular medication:
* Parent or Guardian Signature
Sign Here

PERMISSION FOR FIELD TRIPS

Field trips may be scheduled from time to time throughout ALFAL Youth Enrichment Center.  We will plan trips in advance and will send home with your child a letter describing the field trip. We will always have adequate supervision and follow established safety guidelines on all field trips.

* I am Willing for my child to participate in field trips with ALFAL Youth Enrichment Center
* Parent or Guardian Signature
Sign Here

PERMISSION FOR PHOTOGRAPHS AND RESEARCH

Pictures and photos are taken of activities from time to time for the purpose of ALFAL Youth Enrichment Center advertisement, newsletter or other publications.  Any children pictured in these publications will not be identified by name.  Please sign below your preference for your child to  participate. 

* I am WILLING for my child to have pictures taken of him/her while attending ALFAL Youth Enrichment Center


From time to time we are asked to allow research to be conducted at our programs by universities or school systems: research will only be allowed by representatives of organizations with proper identification and credentials.  Children who participate will not be identified in any research publication, nor will they be allowed to be removed from the program premises by the researcher.  Please indicate your willingness for your child to participate. 

*  I am WILLING for my child to participate in research studiesResearch Permission
* Parent or Guardian Signature
Sign Here

AUTHORIZED PICK-UPS

Permission is given to the following individuals to be released from the program as stated  below and/or I give permission for the following individuals to receive my child(ren) at the  end of the day. 

* 1.  Name
* Relationship to Child
* Address, City, State and Zip Code
* Area Code and Phone NumberFormat: 555-555-5555
2. Name
Relationship to Child
Address, City, State and Zip Code
Area Code and Phone Number
3. Name
Relationship to Child
Address, City, State and Zip Code
Area Code and Phone NumberFormat: 555-555-5555
4. Name
Relationship to Child
Address, City, State and Zip Code
Area Code and Phone Number

WAIVER OF LIABILITY

I understand that even when every reasonable precaution is taken, accidents can still  sometimes happen.  Therefore, in exchange for me and or my children being allowed to participate in activities, I release ALFAL Youth Enrichment Center and A LIFE FOR A LIFE INTERNATIONAL from ALL liabilities, injuries, losses or damages connected in any way whatsoever to me or my child’s/children’s participation in activities on or off the  premises.  I understand that this release includes directors, administrators, staff and  guests. I have read, understand and I voluntarily sign this authorization and release. 

* Parent or Guardian Signature
Sign Here

EMERGENCY CONTACTS AND PICKUPS

If parent or guardian cannot be located promptly, list in order who is to be contacted:

* 1. Name
* Relationship to Child
* Address, City, State and Zip Code
* Home:  Area Code and Phone NumberFormat: 555-555-5555
* Mobile:  Area Code and Phone NumberFormat: 555-555-5555
Work:  Area Code and Phone NumberFormat: 555-555-5555
2.  Name
Relationship to Child
Address, City, State, and Zip Code
Home:  Area Code and Phone NumberFormat: 555-555-5555
Mobile:  Area Code and Phone NumberFormat: 555-555-5555
Work:  Area Code and Phone NumberFormat: 555-555-5555
* Parent or Guardian Signature
Sign Here