Enrollment

Please be advised that this form must be completed in its entirety in order for your child to be officially enrolled in the Fishing School. No sections may be left blank!

PROGRAM SELECTION

Program Type*

Afterschool
Summer Camp

Your child's school*

Leckie Elementary School
Roots Public Charter School
KIPP DC Smilow Campus
Miner Elementary School

STUDENT INFORMATION

Student’s Full Legal Name*

First Middle Initial Last

Date of Birth*

Gender*

Male
Female

Ethnicity*

Please describe*

Grade in the fall*

Student ID Number (lunch number)*

T-shirt size*

Is your child eligible for free lunch?*

Yes
No

Is your child eligible for reduced lunch?*

Yes
No

Special Services Child Receives*

Yes (Please mark details below)
None

*

Is a language other than English spoken at home?*

Yes
No

Please specify:*

PARENT/ GUARDIAN INFORMATION

Primary Parent or Legal Guardian*

First Last

Relationship to Child:*

Authorized Pick Up*

Yes
No

Email Address*

Telephone Number Type*

Home
Work
Cell

Phone Number*

Address*

Street Address City State / Province / Region ZIP / Postal Code

Secondary Parent or Legal Guardian*

First Last

Relationship to Child*

Authorized Pick Up*

Yes
No

Email Address*

Telephone Number Type*

Home
Work
Cell

Phone Number*

Address*

Street Address City State / Province / Region ZIP / Postal Code

STUDENT HEALTH INFORMATION

Do you receive Medicaid?*

Yes
No

Allergies (Write "N/A" if it does not apply):*

Chronic Disorders (epilepsy, diabetes, asthma, etc.) Write "N/A" if it does not apply:*

Current Medications (Write "N/A" if it does not apply)*

List any limitations on your child’s physical activity (Write "N/A" if it does not apply)*

Health Insurance Information

Medical Insurance Carrier*

Group or Policy #*

Name of Insured*

TFS staff does not administer or provide any type of medication to students. Please list all medications your child takes, including those that are administered during the school day.

EMERGENCY MEDICAL CONSENT FORM

If your child needs medical care, the law requires that you, the parent or legal guardian, give your permission to treat the child. In case of an emergency, we will try to contact you. If time does not permit or we are unable to reach you, this form will allow us to have your child receive the attention he/she needs.

I, the parent or legal guardian of*

hereby grant my permission for The Fishing School and its employees to seek emergency medical care for the above-named child when the child is attending the program as they deem it necessary. I also give my consent to any emergency medical care or treatment deemed necessary by such medical personnel for the physical well-being of my child. The medical care shall cover illnesses, accident, and/or injury. In the event of treatment when consultation or follow up care is required, it is my desire that our Doctor,

Doctor (name)*

be contacted at,

Doctor (phone)*

The Fishing School is not responsible for the costs associated with treatment for any incident that may occur during the program.

I understand that without this consent, no treatment will be given to the above-named child.

Parent/ Guardian Signature*

Date*

PICK UP AUTHORIZATION

All participants who are picked-up must be signed out by either the parent or an authorized person listed in this section of the TFS enrollment application. TFS will only release your child to people listed on this form. ID will be requested.

Please choose ONLY one*

Allowed to leave by himself/herself (Walking, taking Metro etc.)
Someone will pick up my child

All parents must have at least one additional person listed as an authorized pick-up. The below mentioned people may pick up my child(ren). The Fishing School will not release a child to any persons who are not listed here and who cannot present a photo ID. If I, the parent, am not available due to an emergency, please contact the people listed below.

Full Name*

First Middle Initial Last

Relationship to Child*

Address*

Street Address City State / Province / Region ZIP / Postal Code

Telephone Number Type*

Home
Work
Cell

Phone Number*

Full Name

First Middle Initial Last

Relationship to Child

Address

Street Address City State / Province / Region ZIP / Postal Code

Telephone Number Type

Home
Work
Cell

Phone*

Full Name

First Middle Initial Last

Relationship to Child

Address

Street Address City State / Province / Region ZIP / Postal Code

Telephone Number Type

Home
Work
Cell

Phone Number*

Full Name

First Middle Initial Last

Relationship to Child

Address

Street Address City State / Province / Region ZIP / Postal Code

Telephone Number Type

Home
Work
Cell

Phone Number*

Full Name

First Middle Initial Last

Relationship to Child

Address

Street Address City State / Province / Region ZIP / Postal Code

Telephone Number Type

Home
Work
Cell

Phone Number*

AUTHORIZATION FOR PHOTOGRAPHY, VIDEOTAPE, AND AUDIO PRODUCTIONS

*

I hereby grant permission for The Fishing School and news media covering The Fishing School to use my child’s photograph in videotapes, publications, motion pictures, recordings, social media posts, and all other events. I also consent to the use of my child’s written work in TFS publications. I hereby release The Fishing School’s programs from any forms of payment involving the current or future use of photographs, videotapes, or audio recordings for which they have performed.

This statement is hereby acknowledged and agreed upon by me, with the full understanding that any photographs, video, audio tapes, or work produced by the child while attending programs, will be freely used by The Fishing School program for public display in either printed or electronic material for the purpose of furthering the business interest of the program.

AUTHORIZATION FOR RELEASE OF EDUCATIONAL INFORMATION

*

I hereby authorize and consent my child's school to provide information concerning education to The Fishing School and United Way of the National Capital Area. I further authorize my child's school to release educational records pertaining to my child for the current school year to the parties listed above that include the following information: education transcripts, school / program enrollment information, universal student ID, attendance data, credit history, grades, assessment data, IEP information and graduation attainment (12th grade only).

This authorization and release shall remain in effect from June 25, 2018 - July 31, 2019. By checking his box, 1) I acknowledge and understand that I have the opportunity to review the records disclosed and the right to challenge the contents of such records; and 2) I am at least 18 years of age or signing this document on behalf of my child because he/she is not 18 years of age.

TRANSPORTATION AND FIELD TRIP CONSENT

*

I agree to allow my child to ride in any bus or vehicle operated or contracted by The Fishing School, in order to participate in program-related activities.

GENERAL CONSENT

*

I agree to attend a parent orientation before my child can be officially accepted into The Fishing School.
I understand and agree to The Fishing School’s attendance policy.
I acknowledge that violations of The Fishing School’s guidelines may result in suspension and/or termination from The Fishing School.
I also understand that my child will sign a commitment and will be expected to honor it. In the event he/she attended school, but cannot attend afterschool for any reason, I will contact The Fishing School on the day of absence and will provide my child with a note when he/she returns to the program. For planned absences, I will contact The Fishing School at least one week in advance.

GENERAL RELEASE & WAIVER

The General Waiver MUST be signed in order for youth to be accepted into the program.

I, the undersigned, am the parent and/or legal guardian of the minor child listed on the first page of this registration form. In consideration for my child’s participation in the programs of The Fishing School, I hereby fully release, waive forever, and hold harmless The Fishing School, its officers and directors, contractors, employees, program staff, agents and volunteers from any and all liability arising from or in connection with any loss, damage, personal injury, including permanent disability or death, arising out of or in connection with my child’s participation in the programs offered by The Fishing School, including but not limited to transportation. For purposes of this release and waiver, the term “liability” means all claims, demands, losses, causes of actions, suits or judgments of any and every kind that arise as a result of my child’s participation in the programs offered by The Fishing School, including liability that may arise out of perceived negligence on the part of persons mentioned above. I acknowledge that some recreational activities offered by The Fishing School involve an element of risk or danger of accidents, and knowing those risks, I hereby assume those risks. This release and waiver explicitly includes any liability which may arise out of my child’s leaving the school without sign out or under adult supervision. I represent that I am over the age of eighteen (18) and that I have read the foregoing in its entirety, that I understand its meaning, and that I am intending to be legally bound by its terms. I understand that this release and waiver is intended to be as broad and inclusive as permitted by law.

I hereby attest to the truthfulness of all information listed on this application and agree to all the above terms and conditions.

Parent/Guardian Signature*

Date*

TFS Amendment to Registration Form

The Fishing School

2019 - 2020 Participant Registration Form

PROGRAM SELECTION

STUDENT INFORMATION

PARENT/ GUARDIAN INFORMATION

STUDENT HEALTH INFORMATION

Health Insurance Information

EMERGENCY MEDICAL CONSENT FORM

PICK UP AUTHORIZATION

AUTHORIZATION FOR PHOTOGRAPHY, VIDEOTAPE, AND AUDIO PRODUCTIONS

AUTHORIZATION FOR RELEASE OF EDUCATIONAL INFORMATION

TRANSPORTATION AND FIELD TRIP CONSENT

GENERAL CONSENT

GENERAL RELEASE & WAIVER