Date: __________________ Grade Fall 2013: _______________ Student’s Name: ______________________ ______________________ ______ Birth Date: ________ Student Lives with: Both Parents ☐ Mother ☐ Father ☐ Other ☐ Address___________________________________________________________ City/State: _____________________________ Zip Code: ___________________ Home Phone: _______________ Main Address: ________________________ There may be an occasion where the school needs to close on short notice, i.e.., Severe weather, local emergency, etc. For this reason we MUST have at least (2) Two emergency contact numbers. Mother’s Name: _________________________ Wk.#: _________________ (Or Main Guardian) Cell#: _________________ Father’s Name: __________________________ Wk.#: _________________ Cell#: _________________ Other Authorized 1._______________________ Phone#:________________ Pick Up Persons: 2._______________________ Phone#:________________ If your child has allergies, medical conditions, or is on regular medication, please list: _______________________________ ______________________________ Doctor Name & Number: _______________________________________________ Preferred Hospital & Number: ___________________________________________ Insurance Provider & Policy Number: ______________________________________ Provider Call#: _____________________________________________________ Students left after closing time in Aftercare are considered, by the State of New Mexico, to have been abandoned. Part I Last First Middle Initial List Order of Emergency Contact #’s to be Called Starting with 1 st  ☐☐☐☐ ☐☐☐☐☐☐☐☐

Terms and Conditions for Aftercare and After School Clubs: All school rules including those regarding dress and behavior are continuously enforced while on campus at any time. This includes the rule of NO cell phones or electronic devices. Parent/Guardian MUST sign out each student everyday. All students who are not signed out after club meetings will be sent to Aftercare. Each family must complete, in its entirety, an After School Program Registration and Emergency Information form per student, to be distributed to all Club leaders and kept on file in the Aftercare room. If you do not plan to utilize any after school programs, you are still required to fill out the information portion of the form in case of a unscheduled or emergency situation. Every OLA student will have a completed and signed permission slip to attend Aftercare. Aftercare fees will be posted regularly in the Sycamore accounts webpage. Payments must be received before the end of each month. Students may not attend Aftercare or Clubs until all outstanding financial obligations to the school are current. Students MUST maintain adequate grades in order to participate in after school Clubs. Students left after closing time in Aftercare are considered, by the State of New Mexico, to have been abandoned. Please write in the Course title/s, fee (if applicable) and total. Skip this section if you are not registering for an After School Program. (Make checks payable to the class leader that is specified if a fee is required.) Course: _______________________________________________________ Fee: _________ Course: _______________________________________________________ Fee: _________ Course: _______________________________________________________ Fee: _________ Course: _______________________________________________________ Fee: _________ Course: _______________________________________________________ Fee: _________ Course: _______________________________________________________ Fee: _________ Course: _______________________________________________________ Fee: _________ Total: _________ We, the parents/guardians of _______________________________________________ have read and agree to comply with the information, terms, and conditions regarding the use of OLA’s Aftercare Program and/or After School Clubs. We have discussed the terms and conditions with our student and have made clear that these terms and conditions (rules) are to be followed by my student at all times. We agree to abide by the rules and regulations of the program/s. ____________________________________________ Parent/Guardian Signature ___________________ Date Part II Office Use Only Date & Time Submitted: