2023-2024 STAR After-School Program Application 2023-2024 STAR After-School Program Application A STAR application must be completed before your child can attend during the 2023-2024 school year. Child's First Name: * Child's Last Name: * Current Grade (K-5) * Birthdate * Sex * Female Male 1st Parent/Guardian Name * Email Address: Unless otherwise specified, this is the email address that will be used for billing. * Phone #1 * Phone #2 * Mailing Address, City, Zip Code * 2nd Parent/Guardian Name 2nd Parent/Guardian Phone #1 2nd Parent/Guardian Phone #2 2nd Parent/Guardian Mailing Address, City, Zip Code (if different from 1st Parent/Guardian above) 2nd Parent/Guardian Email Address Emergency Contact NAME #1 if parent/guardian(s) are unable to be reached. This person has permission to pick up your child: * Emergency Contact #1 PHONE: * Emergency Contact and Permission to Pick-up #2 NAME: (other than parent/guardian) Emergency Contact #2 PHONE: Health concerns, developmental or learning disabilities, or dietary restrictions: * Allergies, including drug reactions and treatment * Current Medications (including epipens or insulin) *Please Note: if meds are to be given at STAR, a separate medication form is required. * Any other information or special instructions that may be helpful to staff when working with your child. * Sunscreen Release: * YES NO I authorize Island Rec staff to apply sunscreen to my child as appropriate. Self Sign-Out Authorization: * YES NO My child has my permission to leave the STAR program alone, without being accompanied by an adult at a pre-agreed upon time communicated with STAR staff. Field Trip Authorization: * Field Trip Authorization: My child is allowed to participate in all field trips using Island Rec's van or by walking, or any bus chartered by Island Rec. Island Rec's van has capacity for six booster seats. I authorize Island Rec to transport my child using a lap belt only. Medical Release: * In the event of a medical emergency, I understand every effort will be made to contact me. If I cannot be reached, I authorize and consent to medical, surgical and hospital care, treatment and procedures to be performed for the child named on this form by a licensed physician, health care provider, hospital or aid car attendant when deemed necessary of advisable by the physician or aid car attendant to safeguard my child's health. I waive my right of informed consent to such treatment. I also give my permission for my child to be transported by ambulance or aid car to an emergency center for treatment. I assume full financial responsibility for emergency treatment of my child. COVID-19 Waiver * COVID-19 WAIVER: CORONAVIRUS / COVID-19 WARNING & DISCLAIMER Coronavirus, COVID-19 is an extremely contagious virus that spreads easily through person-to-person contact. Federal and state authorities recommend social distancing as a mean to prevent the spread of the virus. COVID-19 can lead to severe illness, personal injury, permanent disability, and death. Participating in SAN JUAN ISLAND PARK AND RECREATION programs could increase the risk of contracting COVID-19. SAN JUAN ISALND PARK AND RECREATION DISTRICT in no way warrants that COVID-19 infection will not occur through participation in SAN JUAN ISLAND PARK AND RECREATION programs. Waiver: * I am fully aware of the fact that there are special dangers and risks inherent in the STAR Program, including, but not limited to, the risk of serious physical injury, death or other harmful consequences that may arise or result directly or indirectly to me or my child from participation in this activity. Being fully informed as to these risks and in consideration of being allowed to participate in district sponsored activities and/or use of district facilities, I hereby assume all risk of injury, damage and harm to myself or child arising from such activities or use. I also hereby individually and on behalf of my heirs, executors and assigns, release and hold harmless Island Rec, its officials, employees and agents and waive any right of recovery that I might have to bring claim or a lawsuit against them for any personal injury, death, or other consequences occurring to me arising out of my voluntary participation in these programs. STAR Parent Packet * I have read and agree to the policies, procedures and expectations in the STAR Parent Information Packet. Release of Confidential Student Information from Friday Harbor Elementary School: * San Juan Island Park and Recreation District (Island Rec) and Friday Harbor Elementary School can provide the best services when the school and Island Rec can share important information about your child for the purposes of program planning, staffing and safety. This release allows the school to share information about your student with Island Rec and for Island Rec to be able to share information about your child with the school on a need-to-know basis. I understand that: • This consent allows records and information about my student’s behavior, safety, education, health, Individualized Education Plan and social skills to be shared between San Juan Island Park and Recreation District and Friday Harbor Elementary School. • San Juan Island Park and Recreation District will use any confidential information received under this waiver for the purposes described above and will keep all information about students confidential as required by law. I consent to the use/disclosure of the above information and/or records. Parent/Legal Guardian Name, authorizing the above: * Relationship to Child (e.g. Mother, Father): * Date * If you are human, leave this field blank.