2018 - 2019 Action 330 Program Registration Form - Elementary School Action 330 (School) Location Child Attends __________________________________________ 1 Male
Date child will begin Action 330 _________________________ (1 business day wait before attending)
1 Female
44
Student’s Name ______________________________________________ Date of Birth_______________ Grade___________ (First) (Last) Address _________________________________City_________________________ Zip___________________ Name of Person Paying ______________________________________________ Phone_______________________ Email ____________________________________________
YES, Please sign me up for the Monthly E-Newsletter
qFull pay - Payment due at the time of registration qBi-weekly installment bills (16 bills) qMonthly installment bills (8 bills)
qCheck
$250 yearly program fee per child. For installment billing, a $40 deposit per household will be required at the time of enrollment.
Make checks payable to the WA-WM Recreation Department
qCash
qCredit Card**
**Credit Card Online, In House or by Phone
Enrollment & Emergency Information
Days Attending (please circle) Mon Tue Wed Thurs Fri
Usual Time of Pick Up _______________
Program ends @ 5:30pm
Allergies or Medical Concerns ___________________________________________________________________
Parent Name ______________________________________ Phone Number _______________________ Home / Cell / Work Name ____________________________________________Phone Number _______________________ Home / Cell / Work Name ____________________________________________Phone Number _______________________ Home / Cell / Work
Pick Up Information
It is the responsibility of the parent to notify staff of who will be picking up, and if any changes are being made. Indicate the people that are authorized to pick up your child. Students enrolled in Action 330 are not able to sign themselves out. Name ____________________________________________Phone Number _______________________ Home / Cell / Work Name ____________________________________________Phone Number _______________________ Home / Cell / Work Name ____________________________________________Phone Number _______________________ Home / Cell / Work Name ____________________________________________Phone Number _______________________ Home / Cell / Work Name ____________________________________________Phone Number _______________________ Home / Cell / Work
The signature of a parent/guardian is required for youth registration. I, the undersigned or parent/guardian of the individual(s) named above, do hereby agree to indemnify and hold harmless the West Allis-West Milwaukee School District and its employees, officers and agents from and against any and all liability resulting from participation in the activities listed below. I understand that the program(s) in which I am enrolling, like all activity programs, has some inherent risk, for which I agree to assume the liability, Furthermore, the individual named herein are in good physical health appropriate for the activities in which they will be participating. I understand that the West Allis-West Milwaukee School District does not provide accident insurance. Signature (parent/guardian of minors listed above) _________________________________________________________
Registration
In the event of an illness or emergency, we will always attempt to contact the parent listed below first. If the parent cannot be reached, please indicate who we have permission to contact in order of preference.