One T-shirt provided; additional T-shirt available for $9.00 and must be prepaid at the bottom of this form.
Emergency Contact 1
Physician & Medical Information
Consent and Release
General Parental/Guardian Consent: As Parent/Guardian I/WE hereby affirm that the student is in good health and suffers from no illness, disability, or condition that requires the taking of medication on a regular basis unless that condition is disclosed and approved by program staff. Furthermore, I do not know why the student cannot participate in vigorous physical activity.
I/We expressively agree to be responsible for any medical bills incurred in the treatment of any illness or accident. In the event of any such accident or injury, I /We hereby consent to allow any of the program supervisors to procure any medical treatment deemed advisable on behalf of your child or ward without prior consent.
I/WE understand that, as a condition of admittance as a program participant, I/We, on behalf of all parents and guardians, and on behalf of the student, hereby release The Village Group and its affiliated programs, and all other employees or agents of The Village Group from any and all liability from injury or illness, mental or physical, suffered by the program participant during or related to the program, unless caused by a willful act or gross negligence by the person or entity against whom the claim is made.
Medical Release: As Parent/Guardian I/We hereby give permission to The Village Group staff/volunteer to proceed with emergency treatment in the event of accidental injury or illness provided the immediate family or listed emergency contacts cannot be reached.
PHOTO RELEASE: I further authorize The Village Group, its affiliates, its successors, or its assigns, the right to take photographs of my child/ward for marketing and other purposes, as it deems
Student Record Release
The purpose of the Federal Educational Rights and Privacy Act of 1974 is to protect the privacy of information concerning individual students by placing restrictions on the disclosure of information contained in a student’s education records. By signing below, I/we understand that as a condition of admittance as program participants, my student records including but not limited to (attendance, test scores, class records, etc.) will be used in program evaluation. hereby authorize Georgetown County School District to release my education records (individuals age 18 and older) or the education records of my child, as described below:
Individual(s)/Organization(s)/Agency(ies) to Whom Records May Be Disclosed:
The Village Group Purpose of Disclosure: To obtain, thru power school and local school officials, student level participation (attendance), testing information, and report cards.
One T-shirt provided; additional T-shirt available for $9.00 and must be prepaid before ordering. List the number of extra shirts (Final order date May 4th )
You may choose to pay the Tuition Fee at this time. If you prefer to pay for the Tuition Fee at a later date please use the separate Tuition form located here: https://thevillagegroup.org/after-school-programs/plantersville-summer-academy/plantersville-summer-academy-tuition-fee/