Name of Student (required)

Grade (required)

Name of School (required)

Teacher (required)

Parent/Guardian Name (required)

Phone (required)

Your Email (required)

Emergency Contact (required)

Phone (required)

I understand that enrichment classes are a privilege. I will take responsibility to have respectful behavior and consistent attendance in all After-School Enrichment Program Classes. I understand that if I miss more than two classes or misbehave, I will be asked to leave the classes and another student will replace my spot. I understand that I will not receive a refund for the cost of the class.

Parent or Legal Guardian Signature: (required)

Name of Parent or Legal Guardian Signature:(required)

Date of Signature: (required)

Student/Participant Signature: (required)

Student/Participant Signature:(required)

Date of Signature: (required)

After my class:

The child is being picked up by a parent

By an authorized 3rd person. (the parent must specify the name and relationship such as: "My child will be picked up by the babysitter (Ms. XYZ or Ms. XYZ)

My child is being picked up by a grandparent Ms/Mr XYZ)

My child will walk home.

My child will go to 4R

Base or the schools supervised extension room.

If I fall to do so, my child will be dropped from the Enrichment class.

I understand that I must pick up my student promptly at 3 pm.

Does your child have any allergies?

No Yes

If there is a fee, send your child with cash payable to Two Rivers PTA in a sealed envelope at sign up.