Student's name:_______________________________________ Grade_______________

Email:_______________________________________________ Phone _________________________

Emergency Contact : __________________________________________________________________

Phone # _________________________________________

Programs student will be participating in:






A contribution of $20.00 per program is suggested. We ask that you contribute what you feel you are able, to assist in covering program costs. Please do not let the inability to contribute the full suggested amount keep you from enrolling.

I give permission for my son/daughter, _________________________________ to participate in the FRESH programs. I understand that there may be some risks involved in some in some programming offered. I here by release the Wings Community Programs, Twin Valley High School, Deerfield Valley Community Partnership and their staff from all liability for any injury that may occur while my child is participating in this activity. In the event of illness or injury, I give my consent to provide emergency medical care. I understand that transportation to and from programs is not provided and is not the responsibility of FRESH programs.

By Signing Below, i give permission for my son/daughter to participate in FRESH programs.

_______________________________________________________ date __________________