In the event I am unable to pick up my child, I authorize the following persons to pick up my child. (Please state their relation to the child)
Rules, Regulations & Policies *
I have read and understand the rules and regulations and accept them for my child. Furthermore, I hereby give my consent for my child to participate in the Aransas Pass for Youth Latchkey Program. If in the judgment of any representative of the Aransas Pass for Youth, my child needs immediate medical treatment as a result of an injury or sickness, I hereby request, authorize and consent to such treatment as may be given to said child by any physician, trainer, nurse, hospital or qualified medical personnel. I also hereby agree to indemnify and save harmless the Aransas Pass for Youth Organization and any representative of said organization, the Aransas Pass I. S. D., the Aransas Pass Chamber of Commerce, or anyone else directly or indirectly involved in this program from any claim by any person, whomsoever, on account of such treatment of said child.
The Aransas Pass Chamber of Commerce, Aransas Pass ISD, and Aransas Pass for Youth, Inc., or their employees will not be held liable for accidents occurring while your child is participating in the After School Program. We will not carry liability insurance on your child to cover any medical expenses that may occur due to his/her participation in the After School Program.
It is the responsibility of the parent to pick up their child at the appropriate time, no later than 6:00 pm.
Your child can and will lose their right to participate in the Latchkey program if they are not picked up at the appropriate time. If your child is not picked up by 6:10 pm they will be released to Child Protective Services.
Internet Release *
In consideration of the privilege of my child using Aransas Pass ISD’s electronic communications system, and in consideration for having access to the public networks, I hereby release Aransas Pass ISD, Aransas Pass Chamber of Commerce, and Aransas Pass For Youth, Inc., or their employees, its operators, and my child’s use of, or inability to use, the system, including without limitations, the type of damage identified in the district’s policy, which is available upon request; and administrative regulations.
By typing your full name below you give your child (name listed above) permission to participate in the Aransas Pass for Youth Latchkey Program including all scheduled activities. You also signify that you the parent/guardian agree to the below statements.
I authorize the Aransas Pass Chamber of Commerce, Aransas Pass for Youth, Inc. and the Aransas Pass Independent School District, its employees and volunteers to transport my child to the Latchkey Program. I also certify that I will not hold the Aransas Pass Chamber of Commerce, Aransas Pass For Youth, Inc. or the Aransas Pass Independent School District , their employees, or volunteers legally or financially responsible for any injuries or accidents that may occur during the transit to and from the program. I assume complete and full responsibility for any injury that might occur to my child or intentionally caused by my child.
Additionally, being the parent/guardian of the above named minor and the person having the power to consent to medical treatment of the above named child. I authorize the AP for Youth Staff to consent to emergency medical treatment of the above named child, when I cannot be contacted to do so. Such medical treatment to include without limitation, medical and dental examination, diagnosis and treatment, including but not limited to hospitalization, surgery, x-ray, anesthesia, and medication. No prior determination of life threatening emergency or danger of serious or permanent injury resulting from delay of treatment need be made under this authorization.
I SPECIFICALLY CERTIFY AND AGREE THAT:
This authorization is given in advance of any specific diagnostic treatment of hospital care being required but is given to provide authority and power on the part of Aransas Pass For Youth Staff to give specific consent to any and all such examination, treatment and/or hospital care. I will indemnify and hold harmless from any expenses or claims of any nature, any entity which provides or is caused to provide examination, treatment or hospital care pursuant to this Authorization and agree to make or cause to be made, by assignment of third party benefits or otherwise, full and complete payment for such examinations, treatment or hospital care.
This authorization is limited to emergency treatment necessitated only during the hours in which the above named child participates in the Aransas Pass for Youth Latchkey Program, and thereafter until I can be contacted. The possession of the original of this Authorization by the Aransas Pass for Youth, Inc staff is evidence that he or she has temporary care and control of the above named minor in the event I cannot be contacted or until I can be contacted.
My typed signature below affirms that my child has no medical condition which might make it dangerous for him/her to participate in the Latchkey Program.