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Date*
MM slash DD slash YYYY
Child's Name*
Child's Grade*
Name of Parent(s) / Guardians*
Address*
Phone Number*
Name and Phone Number of Two Emergency Contacts*
Person Responsible for Pickup (Name and Relationship)*
I/We the parents of the above named child (ren) hereby give my/our approval to his/her participation in any and all of the activities of Future Ties, NFP after school program. I/We assume all risks and hazards incidental to the conduct of the activities. I/We hereby waive all claims against the organizers, sponsors, directors or any of the supervisors in case of injury to my child (ren). I hereby authorize Future Ties, NFP to transport my child on Future Ties, NFP Van/ buses to and from school and program activities where applicable. I hereby authorize my child to participate in field trips and activities that occur outside of Future Ties, NFP. I give permission for my child’s photo and artwork to be used in all forms of Future Ties, NFP publicity, brochures and web site.
*
- I Agree
Medical History*
Please indicate any physical or medical concerns that Future Ties staff needs to be aware of, including allergies, medications, surgeries, or serious injuries.
Email
This field is for validation purposes and should be left unchanged.

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Your donation keeps our programming accessible for children and families in the South Side of Chicago.

Thank you!

6418 S King Dr.
Chicago, IL 60637, USA (site location only)

(773) 869-5777

[email protected]

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