After-School Permission Form
Did your Child attend After-School or English Camp this year?
Yes
No
Childs Name
*
First Name
Last Name
Childs Birthday
*
-
Month
-
Day
Year
Date
Child's Gender
*
Male
Female
Does your child or youth have allergies? Please write below.
School Name
*
Child 1 Grade
*
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
Do you have another child attending?
*
Yes
No
Child 2 Name
*
First Name
Last Name
Child 2 Birthday
*
-
Month
-
Day
Year
Date
Child 2 Gender
*
Male
Female
Does your child or youth have allergies? Please write below.
Child 2 School
*
Child 2 Grade
*
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
Do you have a 3rd child coming?
*
Yes
No
Child 3 Name
*
First Name
Last Name
Child 3 Birthday
*
-
Month
-
Day
Year
Date
Child 3 Gender
*
Male
Female
Does your child have allergies? Please write below.
Child 3 School
*
Child 3 Grade
*
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
Mother's Name
*
First Name
Last Name
Mother's Phone Number
*
Please enter a valid phone number.
Fathers Name
*
First Name
Last Name
Father's Phone Number
*
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
I give my child or youth permission to attend PLI's youth program. I do not hold PLI responsible for any sickness or injuries that may happen to my child or youth while there. I give PLI permission to seek medical care if my child or youth should need it while at PLI's program.
*
Please Select
Agree
Disagree
Do we have permission to take pictures and videos of your child or youth during PLI's youth programming
*
Please Select
Yes
No
Does your child or youth have permission to leave PLI to go home without supervision?
*
Yes
No
If you are not comfortable with your child or youth leaving PLI alone, who will be responsible to pick them up?
PLI is not responsible for your children or youth once they leave PLI property.
Signature
*
Submit
Should be Empty: