extracurricular activity form

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EXTRACURRICULAR ACTIVITY FORM
Please use separate form for each activity and for each child!
Activity:
Girl’s Basketball
Activity Fee:
$125
Student Name (Print):
Parent Name (Print):
Email:
Address:
City:
Emergency Contact Information
Name (Print):
Cell Phone:
State:
Zip Code:
Relationship to Student:
Evening Phone:
BASIS Expectations:
Academic: In order to qualify for any Extracurricular Activity students must maintain their level of academic achievement. If a student
is placed on Academic Probation (see Parent & Student Handbook) by a Lower or Upper School Director, the student may not be
permitted to continue participation in the extracurricular program.
Discipline: Students must abide by both the Code of Conduct and Discipline Policies in the Parent & Student Handbook and the specific
rules set by the Activity Manager. The school reserves the right to exclude students from the activity for disruptive behavior or other
misconduct.
Late Pick-up: Parents are expected to pick up their child at the conclusion of the activity session. If a student is not picked up on time,
the child will be supervised by the Late Bird Program manager until the parent arrives, and the parent will be charged the Late Bird fee
for this time. In the case of multiple occurrence of late pick up (more than twice during the school year for any extracurricular activity)
the student may be excluded from future sessions.
Transportation: BASIS does not provide transportation. Parents are responsible for arranging transportation for students to and from
activities, unless specified otherwise.
Financial: If there is insufficient enrollment for this activity by the fee collection deadline the activity will be canceled and collected
money returned.
Refunds: The Extracurricular payment IS NON-REFUNDABLE FOR ANY REASON. This includes but is not limited to the following: an
absence, an academic or non-academic (BASIS or non-BASIS) engagement, a withdrawal from BASIS, or a discipline or academic
problem which resulted in exclusion from the program.
Payment: Please use your SMART for Charters account to pay for all sports and extracurricular activities.
My signature certifies that I have read and understand the expectations stated above.
______________________________
Parent/Guardian (Payer) Signature
PLEASE COMPLETE BOTH SIDES
___________________________
Date
RELEASE AND WAVIER OF LIABILITY AGREEMENT
I, ____________________________ (Student Participant), acknowledge that I have voluntarily
applied to participate in _______________ at BASIS Washington, DC.
I am aware that these activities are hazardous and that I could be seriously injured. I am
voluntarily participating in these activities with knowledge of the danger involved, and agree to
assume any and all risks of bodily injury, death, or property damage, whether those risks are
known or unknown.
I have carefully read this agreement and fully understand its contents. I am aware that this is a
release of liability and a contract between myself and BASIS DC and I am signing it on my own
free will.
______________________________
Student Signature
___________________________
Date
______________________________
Parent/Guardian Signature
___________________________
Date
PLEASE COMPLETE BOTH SIDES
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