FUTURE FOUNDATIONS FAMILY CENTER PERMISSION SLIP  

          (Please Print All Information)     Revised 4/2008

Date  of Application ____________________________

I, the parent of (List all Children and Grade---must be in at least in Kindergarten – 8^th Grade for After school Program)

_________________________,_______________________,_____________________,_______________________

_____________________________________________________________________________________________

give permission for the above named children to participate in activities sponsored by the Future Foundations Family Center and affiliate agencies. I fully understand that my child is to accept all the rules and requirements governing conduct during participation in any and all activities. It is understood that any child determined to be in violation or unfulfilling of these behavior standards will be sent home and could be suspended from further participation. I, the undersigned, hereby release and discharge the Future Foundations Family Center, and all their affiliates, including the employees and volunteers from all liability arising out of or in connection with any FFFC sponsored programs. For the purpose of this agreement, liability means all claims, deemed losses, causes of action, suits, or judgments of any and every kind that I, my heirs, executors, administration or assignees may have against any of these agencies for a death, personal injury or illness, or because of any loss or damage to property that occurs during participation in programs that result from any cause other than the negligence of the entities or their perspective staff members.

Medical Release

In the event of any illness or injury, I hereby consent to whatever medical or dental treatment from a licensed physician and/or surgeon as deemed necessary for the safety and welfare of my child.  I give permission for my child to be transported for such care. It is understood that the resulting expenses will be the responsibility of the parent(s) or participant.

In case of illness or accident, please notify:  HM PH#______________________1. WK PH#____________________

 ________________________________________________________________2. WK PH#____________________

Parent/Guardian                                                Home Address

                                                                                                                HM PH#__________________

1.______________________________________________WK PH#__________________

Alternative Emergency Contact

                                                                                                               HM PH#__________________

2.______________________________________________WK PH#__________________

Alternative Emergency Contact 

Medical Insurance Provider: __________________________Physician ________________PH#________________

Policy Holder Name________________________________ Policy or Group Number_________________________ Allergies/Medical Conditions:______________________________________________________________________

___       _____ My child has permission to walk or bike home on occasions where I have informed them to do so.

Yes        Initial

Special Instructions:                                                                                                                                                            _             

___       ______ I give permission for my child to be photographed while participating in activities that may appear in

Yes         Initial    the newspaper or other media.

___       ______ I give permission for the Grants/Cibola County Schools to share shot records or Free Lunch Form Yes         Initial    information with the Center

___       ______ I give permission for my child to utilize the internet at the Center.

Yes         Initial

OPEN DOOR POLICIES:

For open gym, After School/Summer Programs and other programs with open door policies, Future Foundations Family Center, and other involved agencies are not to be responsible for a child leaving the premises (building and surrounding property) earlier than may have been arranged with a parent, guardian or relative. Only programs with specific enrollment numbers can have these kinds of controls. We will do our best to get to know all the children attending our open programs and their schedules, but we cannot be responsible for enforcing schedules that are prearranged with family or guardians.

________________________________________/_________________________ 

                     Signature of Parent/Guardian                                          Date