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After School Activities Program - ASAP City of Cody Parks & Recreation Department PO Box 2200; Cody, WY 82414 ASAP Cell: (307) 250-8362 STUDENT APPLICATION School Year 2019-2020 (Please complete one application for all children.) Child’s Name: □ F □ M Date of Birth: Grade: Child’s Name: □ F □ M Date of Birth: Grade: Child’s Name: □ F □ M Date of Birth: Grade: Child’s Name: □ F □ M Date of Birth: Grade: School Attending: Guardian’s Email address: Guardian’s name: Circle one: Mom Dad Aunt Uncle Grandma Grandpa Place of Employment: phone: Cell phone: Mailing Address: Guardian’s name: Circle one: Mom Dad Aunt Uncle Grandma Grandpa Place of Employment: phone: Cell phone: Mailing Address (if different): Rec Center Charter Members? □ YES □ NO EMERGENCY CONTACTS/ PEOPLE WHO MAY REMOVE MY CHILD FROM ASAP (A photo ID must be presented if this person is not recognized by staff when picking up your child): (Please list names & contact information in order of preference) Phone Phone Phone Phone Unused Punches: Please select one of the following for your unused punches: Donate to a child in need Put in Household Account for later use Refund check by mail (8 weeks) ---PAGE BREAK--- In case of an emergency, ASAP will call 911 STUDENT INFORMATION Do your children have any illnesses and/or physical conditions staff should be aware of? Please explain: Any allergies or food restrictions? If so, please explain how these should be handled: Additional information about my children I would like to share with HOMEWORK AGREEMENT Homework help will be offered Monday through Thursday each week from approximately 3:45 to 4:30P at ASAP. Please list what help is needed for your child. it is finished OR number of minutes I will be honest with the ASAP teachers about what homework I have and to work diligently to finish my assignments. HOME COURT ADVANTAGE Providing Safety, Belonging, Value & Courage for ALL I, promise to do my part to promote a Home Court Advantage at ASAP: • I will make SAFETY my #1 priority. • I will do my best to make sure everyone at ASAP feels a sense of BELONGING. • I will VALUE myself, my fellow students & my teachers. • I will demonstrate COURAGE to try new things, encourage others & be an active member of this community. Kidz Signature: Parent/Guardian Signature: Date: ---PAGE BREAK--- ASAP RELEASE FORM The City of Cody Parks and Recreation Department does not provide medical insurance to cover participants during an activity. This is the responsibility of each individual involved in any department program or activity. I, hereby give my consent for myself and/or for to participate in recreational activities sponsored by the Cody Parks and Recreation Department in Cody, Wyoming, during any session of the Recreation Program, and to be photographed, interviewed and/or videotaped during these activities. The resulting representation may be used for informational presentations, advertising purposes, and in publications. I hereby release the Shoshone Recreation District, Cody Parks and Recreation Department, Recreation Director, Recreation Staff and Board of Directors, City of Cody and all City Staff associated therewith from all liability, INCLUDING BUT NOT LIMITED TO ALL CLAIMS FOR NEGLIGENCE. This includes but is not limited to claims and suits at law or in equity for any injury, fatal or otherwise, resulting from alleged negligent acts, errors or omissions of the above parties. The Recreation Department may refuse to allow entry or participation by individuals with any behavior and/or conduct that is considered to be disruptive and/or destructive. Behavioral problems may result in expulsion from the program without reimbursement. Your child will be voluntarily participating in an after school program. Even though the activities will take place under careful supervision, it may expose your student to certain hazards and risks. Further, there may be additional hazards and risks associated with the field trips planned occasionally as part of the program (prior notice and permission slips will be provided as needed in these cases). Please initial below the supervised activities your child MAY participate in with your permission: Walking and/or busing to recreation activities within Cody Bus trips within 45 minutes from town Walking field trips Open swimming (Lifeguards will be on duty) Emergency Release: If sudden illness or other serious medical emergency should occur and I cannot be reached, I hereby authorize the City of Cody’s After School Activities Program (ASAP) to provide emergency First Aid treatment and/or call my child’s physician or dentist or 911. Guardian Signature: Date: Late Pick Up Notification: ASAP closes each program day at 6 PM. If children are not picked up on time we will assess a late fee of $10 per 15 minutes late. This fee must be paid before children return to ASAP. If children are not picked up by 6:15 pm, ASAP will notify emergency contacts to pick up the child immediately. Information concerning the children’s whereabouts will be left at the front desk of the Recreation Center. If all resources have been exhausted we will notify the Police Department by 6:30 pm. Children will not be transported by ASAP staff.