RATL After School

WELCOME TO THE RATL AFTER SCHOOL PROGRAM!
Monday-Friday 3:00-5:30pm

Please contact Hayley, RATL Program Director, at hayley@ratl.org if you have any questions.

Student Information

Name

First Name

Last Name

Grade

Birthday

YYYY

Gender

Parent/Guardian Information

Name

First Name

Last Name

Birthday

YYYY

Relationship

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Cell Phone Number

(###)

###

####

Emergency Contact Information

Must list 2; 1 must be local and neither can be Parent/Guardian listed above.

Emergency Contact 1

Name

First Name

Last Name

Phone

(###)

###

####

Relationship

Emergency Contact 2

Name

First Name

Last Name

Phone

(###)

###

####

Relationship

Authorized & Unauthorized Pick-Up

Authorized Pick-Up Contact #1

First Name

Last Name

Relationship

Phone

(###)

###

####

Authorized Pick-Up Contact #2

First Name

Last Name

Relationship

Phone

(###)

###

####

Unauthorized Pick-Up

Person(s) NOT authorized to pick-up your child:

Name

First Name

Last Name

Relationship

Does your child have allergies or special needs? If YES, explain:

EMERGENCY MEDICAL AUTHORIZATION I give RATL permission for my child to be given cardiopulmonary resuscitation (CPR) and first aid treatment by a certified RATL staff member. I authorize my child to be transported by ambulance or aid car to an emergency center for treatment. I authorize RATL to obtain medical care and give consent to the hospitalization and performance of necessary tests, surgery, and the administration of drugs if an emergency occurs when a parent/guardian cannot be located immediately. I understand that the provider will take every effort to contact me and/or my designated emergency contacts. I/we will be responsible for payment of medical expenses.

Parent/Guardian Signature

First Name

Last Name

Medical treatment costs are covered by:

Does your child have medical insurance?

Medical Insurance Provider

Preferred Hospital

Media Release

I consent to the use of myself and/or my minor in photographs, videos, and other media for RATL promotional purposes to be used for advertising, promotional purposes, or other similar purposes, even if my minor is an integral part of the photograph, videotape, motion picture, or other media.

Parent/Guardian Signature

First Name

Last Name

TRANSPORTATION WAIVER

Consent Form and Liability Waiver

Child's Name

First Name

Last Name

Parent/Guardian Name

First Name

Last Name

Activity: RATL After School Program & Field Trips

Individual(s) in charge: RATL Staff

Mode of transportation: Approved RATL Staff in approved RATL vehicle

As parent and/or legal guardian, I remain legally responsible for any personal actions taken by the above named participant(s). I agree to myself & my child(ren) listed above to be transported by RATL Staff & Interns to the location outlined above. I agree on behalf of myself, my child named herein, or our heirs, successors and assigns, to hold harmless Restoration Atlanta (RATL) its officers, directors and agents, and representatives associated with the event, from any and all actions, claims, demands, damages, costs, expenses and all consequential damage arising from or in connection with my child attending the event or in connection with any illness or injury or cost of medical treatment in connection therewith, and I agree to compensate RATL, its officers, directors and agents, or representatives associated with the event for reasonable attorney’s fees and expenses arising therewith.

Parent/Guardian Signature

First Name

Last Name

I agree to the following: ON BEHALF OF THE CHILD REPRESENTED, I RELEASE, WAIVE, AND COVENANT NOT TO SUE RATL, its directors, officers, employees, volunteers, and agents (hereinafter referred to as “releases”) and release the releases from all liability for any loss or damage, including any claim on account of injury to person or property or death, whether caused by the negligence of the releases, while the undersigned or the child is participating in any program sponsored by, operated by or affiliated with RATL. I ASSUME FULL RESPONSIBILITY FOR THE RISK OF BODILY INJURY, DEATH OR PROPERTY DAMAGE to the undersigned and to the child being registered due to the negligence of releases upon the premises of RATL and/or while using the premises or equipment or while participating in any program sponsored by, operated by, or affiliated with RATL. THE UNDERSIGNED further agrees that the RELEASE, WAIVER AND INDEMNITY AGREEMENT is intended to be as broad and inclusive as is permitted by the law of the State of Georgia and that if any portion is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. The undersigned agrees that no oral representations, statements or inducement apart from the foregoing written agreement have been made. The undersigned has read, accurately completed, and agrees to all the information above, including the child’s information, pick-up authorization, drop-off authorization, unauthorized pick-up, parent/guardian authorization, emergency contact, medication disbursement authorization, RATL over-the-counter medication, emergency medical authorization, medical history, medical release, participant waiver form acknowledgement, parent release, indemnification, waiver of liability and indemnity, agreement in consideration, and voluntarily signs the release and waiver of liability and indemnity agreement, and further agrees that no oral representations, statements or inducement apart from the foregoing written agreement have been made. Parent/guardian signature is required on the Photo Release, Medical Release and agreement to follow RATL policies and guidelines for participation in the RATL program.

Parent/Guardian Signature

First Name

Last Name