EE form testing

Step 1 of 2

Student Name *

First

Middle

Last

Sex *

Student Current School *

Grade in Fall *

Mailing Address *

Address Line 1

City

State

Zip Code

Mother's Name: *

Mother's Email *

Mother's Phone *

Father's Name

Father's Email

Father's Phone

Name( Emergency Contact 1 ) *

Work/Cell Phone *

Authorized to Pick-Up?

Name( Emergency Contact 2 )

Work/Cell Phone

Dropdown

Name of Student Physician *

Physician Phone *

Parents Statement of Agreement *

I understand that I am not to leave my child at the ACES site unless there is a ACES staff member present.
I understand that my child will not be allowed to leave the program with an unauthorized person. Only adults (over 18 years old ) can be authorized to pick up the child.
Authorization: In case of an emergency, I understand that every effort will be made to contact me. In the event that I cannot be reached, I hereby give permission to the physician selected by the adult leader in charge to secure proper medical services. I hereby release Austin Chinese Education Services and its staff and aides from all action that may arise from such medical services.
I understand and acknowledge that the ACES does not offer any medical insurance to protect against injuries, makes no claim to do so, and has no responsibility for any medical expenses incurred. I understand that each participant must assume the risk and any related financial responsibility that could result from participation in any of these activities. I agree to assume such risks and such financial responsibility. I further understand that neither the ACES nor its workers can be held responsible in the event of accident.
I authorize for my child(ren) to participate in photos or videos for ACES Classes.
I understand that my child may be removed from ACES program for any of the following reasons:

Failure to pay program fees by designated deadlines
Inappropriate behavior of a child/parent that endangers anyone involved with the ACES
Inappropriate behavior of students that disrupt the class, so that the class cannot function properly