Student Application – Fish Out of Water

Anchors Up Application

Fish Out Of Water Career Development Center, Inc.

Anchors Up! Program
www.fo2w.org

PARTICIPANT APPLICATION

Completed by Student & Parent

Middle School or High School Participants Only, Grades 7th-12th

STUDENT INFORMATION

TO BE COMPLETED BY PARENT/GUARDIAN

CHILD RELEASE CONTACTS: If I am not able to pick up my child following the Anchors Up After-School Program, I give permission for my child to be released from the program and/or to be received at the end of the program day by the following people. I understand that my child will not be released to anyone unless listed below.

Relationship to Participant

MEDICAL HISTORY: Please provide facts concerning your child’s medical history including allergies, medications, and any physical impairments, for which a physician may need to be alerted.

Does your child have a physical impairment, medical condition, or disability?

Yes No

If yes, please list:

Is your child taking any type of medication?

Yes No

If yes, please list:

Does your child have any allergies?

Yes No

If yes, please list:

Does your child have any special dietary needs?

Yes No

If yes, please list:

Medical Insurance Carrier & Number

Parent Email Address:

PARENT ASSENT / WAIVER OF LIABILITY

As parent and legal guardian of the below-mentioned student, I authorize and permit my child to participate in activities, and events offered by the Anchors Up After-School Program. I understand that participant activity records will be kept confidential. Activity data will be coded to protect individuals’ rights to privacy. All records will be stored securely on a password-protected computer to ensure confidentiality of all data elements. I agree that Fish Out of Water CDC, Inc, and anyone associated with Fish Out of Water CDC, Inc. will not be held liable for any loss, injury, or death related to any activities or events. I agree to hold Anchors Up After-School Program, advisory committee members, officers, staff, and volunteers, harmless from any claims whatsoever occasioned in any of the above situations. Further, I have agreed that the Anchor’s Up After-School Program offered by Fish Out of Water CDC, Inc shall NOT be held liable. If my child is involved in a medical emergency, I authorize the Anchors Up After-School Program staff to make decisions regarding immediate medical attention (hospitalization, administration of prescribed medications, doctor treatment, etc.) if they are unable to contact me for verbal authorization.

Would you like to receive information about community resources?

Yes No

PHOTO RELEASE (Please select ONE option below):

PHOTOGRAPHY/VIDEO RELEASE

Students participating in the Anchors Up After-School Program may be photographed, filmed, or interviewed. As the parent and/or legal guardian of the above named student, I grant permission for my child to participate in photographs, videos, or interviews as they pertain to the Anchors Up After-School Program. I understand that such photographs, videos, or interviews may be used to promote or publicize Anchors Up After-School Program, events, educational services. I understand that they may also be used to demonstrate how local, state, or federal funds are being used to assist students.

OPT-OUT OF PHOTOGRAPHS & VIDEOS

I choose to opt-out of photographs and videos. DO NOT photograph or video my child for publication.

PARENT CONSENT/PERMISSION:

Parent / Legal Guardian Signature