(if applicable)

(other than Parent/Guardian)

The 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.

We 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!

Please contact the Director of the 21st CCLC Program with any questions about these releases and permissions.

Each week we will be going on a field trip 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. 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.

This form gives permission for your child's photograph and/or video to be used to advocate and/or publicize our 21st CCLC Program. These publications may be 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.

We 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.

In 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.

By 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.