Fairmount 21CCLC Registration & Release Form Releases & PermissionsPlease contact the Director of the 21st CCLC Program with any questions about these releases and permissions.Field TripsSome of our after school programs will be taking field trips during the normal operating hours, throughout the greater Bangor area. At this time you may give permission for your child to participate in all of the Field Trips. If any field trip falls outside the normal operating hours you will be asked to sign a separate permission slip. By entering my name below, I give permission for my child to participate in all field trips that are part of the Fairmount 21st CCLC Program.Photographs and VideosThis form giver permission for your child's photograph and/or video to be used to advocate and/or publicize our 21st CCLC Program. These publications may b used in our school newsletter, brochures, on our website, television, or any other type of publication. By entering my name below, I give permission for my child to participate in any photo or video session that may be part of Fairmount's 21st CCLC Program.First AidWe do not have nursing services provided during our after school hours of operation. By entering my name below, I confirm that I have been informed and I agree to notify the program of all of my child's medical conditions/needs. I also authorize the 21st CCLC program staff to take the appropriate action to protect the well-being and safety of my son/daughter including seeking emergency medical attention or hospitalization (or both) should the need arise and I am unable to be reached.21st CCLC PermissionIn order to provide evidence to maintain our 21st CCLC grant we need to keep track of student demographics, free and reduced lunch status, academic progress and activity participation. All information collected will be restricted and used solely for serving student needs and program evaluation purposes. By entering my name below, I authorize the release of my child's information in order to provide evidence to maintain Fairmount's 21st CCLC grant and to track overall student progress for program evaluation.Release of LiabilityBy entering my name below, I/we agree to hold harmless and indemnify the Bangor school department, officers, agents, employees, volunteers and contractors from all claims, demands, causes of action that arise from any unintentional or claimed negligent act or omission resulting from any student's participation in the 21st CCLC program.Parent Signature* First Last Child's Name* First Last Grade:*Grade 4Grade 5Gender*FemaleMaleEthnicityChild's Date of Birth* Parent/Guardian 1 InformationParent/Guardian 1 Information* First Last Parent/Guardian 1 Address* Street Address City Parent/Guardian 1 Phone*Parent/Guardian 1 Email* Parent/Guardian 1 Date of Birth* Parent/Guardian 2 Information(if applicable)Parent/Guardian 2 Information First Last Parent/Guardian 2 Address Street Address City Parent/Guardian 2 PhoneParent/Guardian 2 Date of Birth Emergency Contact(other than Parent/Guardian)Emergency Contact* First Last Emergency Contact Relationship to Child*Emergency Contact Phone*Emergency Contact Phone (alternate)Special Conditions(if applicable - Medical Conditions, Allergies, Medications, Dietary Requirements)Medical InformationFamily Physician Name*Physician Phone*Choice of Emergency Room* EMMC St. Joseph's Insurance Info*TransportationMy child will:*Take the busBe picked upWalkAddress for bus drop off:(Bus drop off will be determined based on need and is commonly the closest intersection to your house)Pick-up AuthorizationThe following people, along with parents/guardians and emergency contact listed above, are authorized to pick up my child from the program. I understand my child will be allowed to leave with these individuals only.Pick-up Authorized Person 1 First Last Pick-up Authorized Person 1 Relationship to ChildPick-up Authorized Person 1 PhonePick-up Authorized Person 2The following person, along with parents/guardians and emergency contact listed above, is authorized to pick up my child from the Bangor Parks and Recreation Programs. I understand my child will be allowed to leave with this individual. First Last Pick-up Authorized Person 2 Relationship to ChildPick-up Authorized Person 2 PhoneFeesWe take pride in offering our program to Fairmount families at no cost; however, maintaining a high-quality program is costly, and funding is limited. Any contribution made by participants makes a difference!Contribution* We are able to make a contribution (enter amount below) We are unable to make a contribution at this time Amount of ContributionPlease drop off cash or a check payable to "Bangor School Department 21st Century Program" to Fairmount School.