Student First NameStudent Last NameSelect your student's grade & teacher.Grade-TeacherK-BrunoK-ParrishK-RobicK-Stokley1-Ahern1-Delauter1-Kiel1-Mackauer1-Stewart2-Fatz2-Kelley2-Meadows2-Morris3-Gray-Garry3-Harrison3-Sjostedt3-Street4-Ciancio4-Condon4-Deater4-Wise5-Horton5-Kosman5-Mason5-RobinsonParent/Guardian NameEmail AddressPhone2nd Authorized Adult2nd Authorized Adult's Email2nd Authorized Adult's Phone3rd Authorized Adult3rd Authorized Adult's Email3rd Authorized Adult's PhoneConsent *I have read and understand the Medical Agreement below:All programs are over at 3:30 pm. There is NO extended childcare coverage. If there is an emergency or the student is not picked up at the ending time indicated, and neither parent can be reached, the school's emergency pickup contact will be utilized.Consent *I have read and understand the Good Health Agreement below:As parent/guardian of the above student, I certify that they are able to participation. I understand that the Lovettsville PTO and/or CLINIC PROVIDER do not provide any medical payments coverage (insurance) and I am allowing my child to participate in this event at their own risk. By checking the box above, I agree to pay for any medical expenses incurred by my child as a result of participating in this Lovettsville PTO sponsored activity and of participating in this Lovettsville PTO-sponsored activity and will not hold the PTO Instructor or the staff liable for any reason related to my child’s participation in the program. I also give permission for my child to receive medical treatment, first aid, emergency medical care, and all other medical or surgical deemed reasonably necessary to my child's health and well-being in case of accident, injury, or serious illness during participation in the activity and understand that I, or my insurance, will be responsible on a primary basis for any medical bills incurred.Consent *I have read and understand the Permission for Attendance below:My child has permission to stay for all the sessions of after-school programs of which they are enrolled. Students registered for after-school programs are expected to stay after school for these programs UNLESS a parent or guardian sends in a written note to the school advising the staff that the student will not be staying for the program.Please list any known allergies or other information the instructor should be aware of for the duration of the program.Please enter your student's regular dismissal information (non-asp days).BusCASAParent Pick UpBus NumberIn the event that the activity is cancelled due to weather or any other event, my child should: *Follow their normal (Non-ASP days) dismissalWait for Parent Pick UpSMS Notifications - Remind App *In the event of a change or cancellation, LOV PTO will use the Remind App to notify parents/guardians as quickly and effectively as we can. It is important each parent acknowledges receipt of the notifications as they are received. To ensure we have accurate mobile number, please enter the phone number you would like us to add to the Remind App in the below field.Mobile Phone for Notifications *LOV PTO will be transitioning program updates and cancellation notifications from email to the Remind App. Please verify the mobile number you would like to receive the text notifications.SignatureBy entering my name above, I acknowledge that I have read all the information above and have answered the questions to the best of my ability. I give permission for my child(ren) to participate in the After School Programs offered by Lovettsville PTO.Submit Permission Form