Middle Tree - OMSD 2024/2025 After-School Program Registration for Montera Elementary

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Student First Name

Student Last Name

Student Grade for '24-'25 School Year (New School Year)

Are you enrolling more than one student?

YesNo

Student 2 First Name:

Student 2 Last Name

Student 2 Grade for '24-'25 School Year (New School Year):

Are you enrolling a third student?

YesNo

Student 3 First Name:

Student 3 Last Name

Student 3 Grade for '24-'25 School Year (New School Year):

Are you enrolling a fourth student?

YesNo

Student 4 First Name:

Student 4 Last Name

Student 4 Grade for '24-'25 School Year (New School Year):

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Parent/Guardian First Name

Parent/Guardian Last Name

Phone Number (xxx-xxx-xxxx)

Please provide an accurate and accessible email address that you have regular access to. The program coordinator will email you if your student was accepted, waitlisted, or removed from Middle Tree. All correspondence is communicated via email unless the email is invalid, then phone communication will be utilized.

Confirm Email

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Sign-Out Policy:

All students are required to be picked up by an adult.

Who may also sign your student out? Use their LEGAL name (Must present ID). List at least 3 options:

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Middle Tree LIABILITY RELEASE AGREEMENT (hereinafter “Release)

Minor's Legal Name

(hereinafter “Minor”).

Middle Tree and I, the undersigned parent or legal guardian of the Minor, agree that the Activity (activities include any Middle Tree activities both on and off site) may pose risks, including possible illness, injury, as well as similar and dissimilar risks (hereinafter “Risks”). The undersigned is fully aware of the Risks and other hazards inherent in the Activity and is allowing the Minor’s voluntary participation in the Activity and assumes the Risks and all other risks of loss, damage, or injury that may be sustained while participating in the activity. We are also not liable for personal items and school materials assigned to the student. Middle Tree makes no representations or claims as to the condition or safety of the land, structures, transportation, or surroundings that may be involved in the Activity, whether or not owned, leased, operated or maintained by Middle Tree. It is understood that Middle Tree does NOT provide any insurance coverage for the Minor's person or property, and the Minor's parent(s) or guardian(s) acknowledge that they are responsible for the Minor's safety and the Minor's own health care needs, and for the protection of the Minor's property. In exchange for allowing the Minor to participate in these Middle Tree activities, the Minor, by and through the undersigned, the undersigned, and the Minor’s respective heirs, personal representatives and estates agrees to, in perpetuity, release from liability, indemnify and hold harmless Middle Tree and any agent, officer or employee of Middle Tree acting within the scope of their duties for any injury to the Minor's person or damage to the Minor's property. I authorize Middle Tree to take any appropriate action necessary in its judgment, including seeking medical care, if I am not present or reachable in the event of an emergency. The undersigned acknowledges that as a part of this Release he or she shall be 100% liable for the remuneration of any and all incurred medical expenses resulting from any injury incurred during, or as a result of participation in the Activity. If any term of this agreement or the application to any person or circumstance shall, to any extent, be invalid or unenforceable, the remainder shall not be affected thereby, and each and every remaining term of this agreement shall be valid and enforced to the fullest extent permitted by law. In the event of any need to enforce this agreement, Middle Tree shall be entitled to its attorney fees and costs. This agreement will be governed by California law, County of Los Angeles. I, the undersigned, state that I am the parent or legal guardian of the Minor. I have fully read and understand the above terms and conditions and that they apply to said Minor and to myself, and that no oral representations, statements or inducements apart from the foregoing written agreement have been made to the undersigned. This document is binding on myself, the said Minor, and any person suing on behalf of said Minor.

Parent Guardian Name:

Date:

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PUBLICITY AUTHORIZATION FORM

Middle Tree regularly produces and distributes instructional or promotional materials, both electronic and printed, to students, families, friends, prospective families, and the Educational Community. These materials may include, but are not limited to student-generated projects and podcasts to be shared with students or experts around the world, media placed on District websites, promotional brochures, etc. Once these materials are distributed they often make their way to the public domain and become generally available to the public for view and use.

Please choose from the options below:

I authorize Middle Tree to make (or authorize the making of) photographs, videotapes,

audiotapes, or other media of my child and/or his/her work for publicity, instructional, or

professional development purposes without further notice to me.

I do not authorize Middle Tree to publish my child’s photograph, video image, voice or work for publicity, instructional or professional development purposes.

Parent Guardian Name:

Date:

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Emergency Treatment

If Middle Tree staff deem it necessary, your child will be taken by ambulance to the nearest

emergency facility where the attending physician (or dentist) on duty may perform emergency treatment on your child. All costs incurred shall be at the parent’s or guardian’s expense.

Parent/Guardian Name:

Date:

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EMERGENCY RELEASE FORM (Optional)

Emergency Contact Information:

In the event of an emergency or disaster, your student(s) will only be released to the persons authorized on this form if we are unable to reach you.

I authorize the following individuals to pick up my student(s) in case of an emergency or disaster: (please list names, phone numbers, and relation to student).

Would you like us to add the above contacts as approved individuals to “sign-out” your student(s) from Middle Tree?

YesNo

Parent/Guardian Name:

Date: