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After School Program / Day Camp

  1. After School Program / Day Camp Registration Form

  2. Staff Use Only

  3. Persons Authorized to Pick up Child

    In addition to parents / guardians listed above

  4. Health / Medical Information

  5. Such as ADD, ADHD, allergies, diabetes, seizures, asthma, etc.

  6. Please Note Staff is Not Allowed to Administer Medication

    Programs, services and facilities are available for individuals with disabilities.

  7. Please Initial

    • _____ Children picked up after 6:00pm will be charged a late fee. The fee is $15 for every 10 minutes after 6:01 p.m. Consistent late pick up may result in suspension from program.
    • _____ Children must wear tennis shoes every day.
    • _____ Children cannot bring money to the after school program.
    • _____ Children cannot bring cell phones, toys, MP3 or CD players to the After School Program. All items will be taken up by staff and held until the end of the day and returned to parent.
    • _____ Children who become ill may not remain in the program. A parent or emergency contact person will be called.
    • _____ Parents or authorized adults are required to sign children out every day. Children will not be allowed to sign themselves out, or wait outside the building.
    • _____ Parents will be notified of children who have repeated disciplinary problems. Repeated discipline or behavior problems may result in suspension from the program. NO Refunds will be given for children who are suspended from the program.
    • _____ For the safety of all students: Only persons 18 years or older with a valid driver’s License can sign them out. This includes older siblings; they must be 18 years with a valid Texas ID or DL.

  8. Emergency Release

    In case of emergency, I give the City of Irving, and it’s staff the authority to call for medical attention for my son/daughter while participating in any program, field trip or special event with the Cimarron Park Recreation Center After School Program or any other City of Irving park or facility.

  9. Waiver & Consent Form

    I have read and fully understand and agree to all of the guidelines and regulations regarding the City of Irving Programs. I also agree to follow the guidelines set forth for After School Program.
    I release the City of Irving, its employees and volunteers from all responsibility for any accident or injury that may occur while my son/daughter participates in planned activities at any city of Irving facility, field trip, or water park. I also do not hold the City of Irving, it’s employees and volunteers responsible for any accident or injury to my son/daughter while transporting to and from planned activities, field trip or water park unless negligence is proven.

  10. Photo / Video / Statement Consent & Release Agreement

    By my signature on this form, I authorize the City of Irving and its agents and assigns (hereinafter City of Irving) should it choose, to use my [or my child’s or dependent’s (as applicable)] name, picture, voice, verbal statements, and/or portraits (video or still) in any promotional and/or educational printed or electronic piece that furthers the City of Irving’s public relations and/or educational efforts during this and subsequent years. This includes, but is not limited to, external news media outlets, printed materials, broadcast, web site, brochures, displays, newsletters, or other means of communicating with the public about programs and services in Irving. I further understand that the pictures, recordings, articles, copy, or other means of communications may or may not personally identify me [or my child or dependent (as applicable)]. I release to the City of Irving and consent to the use of my [or my child’s or dependent’s (as applicable)], name, picture, voice, verbal statements, or portraits (video or still).

  11. Waiver

    I waive to the fullest extent that I may lawfully do, any causes of action in law or equity that I may have or may hereafter acquire against the city of Irving arising out of or in connection with the use of my [or my child’s or dependent’s (as applicable)] name, picture, voice, verbal statements, or portraits (video or still).

  12. Affirmation

    I further affirm that I understand and agree that:

    • No monetary consideration will be paid
    • Consent and release have been given without coercion or duress
    • This agreement is binding upon any heirs and/or future legal representatives
    • The photographs, video, and/or statements may be used in subsequent years
    • This consent and release shall be governed by Texas law
  13. Please Print

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