Enrollment Application

SELECT ONE (REQUIRED)

PARENT INFORMATION

EMERGENCY/MEDICAL INFORMATION





LOCAL EMERGENCY










In case of an emergency:
 The parent / guardian will be contacted immediately.
 The child’s physician will be contacted
 We will attempt to contact parent / guardian through one of the emergency contacts listed.

 If the staff of the SMARTs cannot contact your child’s physician, staff will call for emergency first-aid assistance / transportation and/or have the child transported to an emergency hospital in the company of a staff member.

I state that I am the parent / guardian having legal custody of the child name in this document and attest that the information is correct. I authorize the above center project director or the director’s designee to obtain emergency treatment for my child.

Waiver: My child is permitted to participate in: (Please check all activities that apply)
ClubsSports and Recreational GamesAcademicsCommunity Service

(hereinafter called “Activity”), I, for myself, my heirs, personal representatives or assigns, do hereby release, waive, discharge, and covenant not to sue the SMARTs , One Step Forward, DanceMakers, Inc., Prince George’s County Public Schools, administrators, employees, and agents for liability arising from personal injuries, accidents or illnesses (including death), and property loss arising from participation in the Activity.

Image Permission and Release: For Internal and external use, I acknowledge that the SMARTs and/or its sponsors may utilize film, print, and digital images of a student or a family, which may be taken during involvement in the SMARTs activities. I consent to such uses & hereby waive all rights to compensation.

Information Exchanges: I, the undersigned (as a parent or guardian of the participant, a minor), hereby give permission for mutual exchange of information between the SMARTs and the school regarding health and safety issues, food program status, immunization records and academic achievement.

I, the undersigned (as a parent or guardian of the participant, a minor), hereby authorize the staff of the SMARTs volunteers, coaches, trainers, supervisors, instructors and drivers as my agents, to consent to medical, surgical or dental examination and/or treatment. In case of emergency, I hereby authorize treatment and/or care at any hospital or by licensed medical personnel. Staff will NOT medicate children. Parents/guardians are ENTIRELY responsible for medications and for personally arranging for or insuring the proper and timely medicating of their child.

I also understand that students participating in the program will be held to the Prince George’s County Public School’s standards for behavior. Repeated disruptions or disrespect for others and/or for their property may result in suspension or removal from the program.

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