IN APPLYING FOR REGISTRATION IN THE SELECTED COURSE(S), I RECOGNIZE THAT I AM PERSONALLY ASSUMING THE RISK OF ALL LOSS OR INJURY TO MY CHILD OR HIS/HER PROPERTY.  I HEREBY EXPRESSSLY WAIVE AND RELEASE THE BOARD OF EDUCATION OF HOMER COMMUNITY CONSOLIDATED SCHOOL DISTRICT 33C, ITS MEMBERS, OFFICERS, AND EMPLOYEES, FROM ANY AND ALL CLAIMS THAT I HAVE, NOW OR IN THE FUTURE, FOR PERSONAL INJURY OR PROPERTY DAMAGE OR LOSS, ARISING IN CONNECTION WITH PARTICIPATING IN THE SUMMER SCHOOL PROGRAM.

PLEASE NOTE: NEWSPAPERS MAY WRITE ARTICLES AND TAKE PICTURES OF STUDENTS IN THE SUMMER SCHOOL PROGRAM.

 

  PLEASE PRINT PARENT/GUARDIAN NAME:____________________________________________________________

 

  SIGNATURE:_____________________________________________DATE:__________________________________

CANCELLATION OF CLASSES is determined by the enrollment.  All courses are subject to cancellation, if an insufficient number of students is enrolled.  If a course is cancelled, your registration fee will be refunded, or you may select another class from those still open.

The Homer 33-C Summer School Program is now in its 19th year!  We are pleased that your child will participate in our summer school program, and we are sure that it will be a rewarding experience.

Please fill out the following information and submit it when registering.  PLEASE PRINT.  Thank you.

 

                                                                                                                                                 MALE

CHILD’S NAME:_____________________________________ DATE OF BIRTH:_________________ SEX:       FEMALE

 

  HOME PHONE: (           )____________________________CELL PHONE: (          )_________________________

 

  ADDRESS:___________________________________CITY/STATE/ZIP:____________________________________

 

  MOTHER’S WORKPLACE:______________________________PHONE: (          )_____________________________

 

  FATHER’S WORKPLACE:______________________________PHONE:  (          )_____________________________

 

  FAMILY PHYSICIAN:________________________________PHONE:  (          )_____________________________

 

  IF YOUR CHILD HAS ANY SPECIAL MEDICAL PROBLEMS, PLEASE SPECIFY BELOW:

 

__________________________________________________________________________________________

 

___________________________________________________________________________________________

IN CASE OF AN EMERGENCY, WHEN PARENTS CANNOT BE REACHED, PLEASE INDICATE SOMEONE WE COULD ATTEMPT TO CALL WHO WOULD BE ABLE TO COME FOR YOUR CHILD.

 

  NAME:_____________________________________________PHONE: (          )_____________________________

 

  NAME:_____________________________________________PHONE: (          )_____________________________

 

IN CASE OF AN EMERGENCY, WHEN ALL ATTEMPTS HAVE BEEN MADE TO CONTACT PARENTS OR EMERGENCY NUMBERS, I GIVE THE SCHOOL MY PERMISSION TO CALL MY PHYSICIAN, OR TAKE WHATEVER ACTION DEEMED NECESSARY, AND I WILL ACCEPT RESPONSIBILITY FOR ANY EXPENSE INCURRED IN HANDLING THIS EMERGENCY CARE.

 

        YES             NO          SIGNATURE:_________________________________DATE:_____________________