LCYC, INC.

After School Program Registration Form

5 + 12 =

By electronically inputing your signature in the upper categories you are giving consent to:

  1. Acknowledgement that you consent to all the terms set forth by your School Cooperation and the LaGrange Communities Youth Centers, Inc. regarding the After School Program.
  2. “The LaGrange Communities Youth Centers, Inc., volunteer, or any employee of and/or any employee at any locations, are hereby released and discharged liability or damages resulting from any accidental injury occurring to you child, and do hereby agree to release, indemnify, and hold harmless LCYC, Inc.for any and all claims, injuries or cause of action arising or occurring during program participation.”
  3. Permission for your child to be photographed during activities at the LCYC After School Program. These pictures are to be used only for the purpose of the newspaper articles, brochures, and/or publicity directly related to the After School Program activities. Pictures may appear on the LCYC, Inc. Facebook page and the LCYC, Inc. website – However, NO NAMES will be used to identify students.
  4. Permission for you child to walk home from the LCYC, Inc. After School Program, agreeing to contact the LCYC directly if request changes.

Please type N/A if any of these do not apply or if you do not give consent.