Test

Name *
Name
This can be found on your child's report card
Date of Birth *
Date of Birth
Parent's Name *
Parent's Name
Address *
Address
Home Phone
Home Phone
Work Phone
Work Phone
Cell Phone
Cell Phone
Emergency Contact
Emergency Contact *
Emergency Contact
Phone *
Phone
Adult(s) authorized to pick your child up from the program
Adult(s) authorized to pick your child up from the program
Do you consent to your child to receiving medical attention in the event of an emergency? *
Parent Employment Information (This information will be used for statistical purposes only)
Parent/Guardian Statement
I hereby give permission for my child to participate in all activities conducted by the program, including educational activities at the local site, performing and visual arts activities at the local (school) site, field trips to arts and educational activities away from the local (school) site, and sports activities conducted in DCPS and/or DC Dept. of Parks and Recreation facilities. I further grant permission for my child: 1) to appear in person or in voice, video or photographic presentation for noncommercial radio, television, internet or print media reports and/or media campaign(s) resulting from participation in this program and its activities, 2) to complete confidential or anonymous surveys, and 3) to participate in interviews for evaluation purposes. I understand that if my child is not picked up from the local site by closing he/she may be taken to the Office of Child Protective/Emergency Family Services located at 400 Sixth Street, SW (202) 671-SAFE.