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The B.L.O.C.K. Emergency Contact Form 2022 Program Year

  1. Permission for participants to check themselves in and out of After School program and all B.L.O.C.K. functions:*

    My child has my permission to sign him/herself in and out at the beginning, and at the end of the After School program and all other B.L.O.C.K. functions. I understand that Leisure Services staff will not be responsible for my child and any other children I have taken responsibility for once they sign out and separate themselves from Leisure Services staff.

  2. Permission to Record and Photograph Child Participating in Activities:*
    I hereby release to Canton Township rights to my child’s image, likeness, and the sound of his/her voice as recorded or photographed. I understand this recording or photograph may be edited and placed in publications, and thereafter the recording or photograph may be otherwise available. I agree to release, discharge, and save harmless Canton Township, including its representatives or designees, from any legal proceedings which may arise in relation to the conditions of the above paragraph.
  3. (Type Name)
  4. (Type Name)
  5. Permission to Administer Questionnaires to Participants*
    I hereby give Canton Township my permission to administer questionnaires to my child for the purposes of improving future programs. I understand that the information collected from my child will remain anonymous and that my child’s identity will not be revealed in relationship to the survey.
  6. In consideration of Canton Township permitting my child to participate in B.L.O.C.K. events off-site and providing transportation to and from said events, I, on behalf of myself, my child, my heirs, successors and assigns, hereby release Canton Township, its elected and appointed and officials, and its employees, volunteers, and agents, as well as the representatives of any other organization connected with this event, from any and all claims for liabilities or damages for any and all property damage or injuries which my child may suffer while taking part in any activities connected with this event. In case of injury, and I am unable to be contacted by your staff, I give my consent to have medical treatment administered to my child if deemed necessary by a physician and understand I shall be liable for any costs associated therewith.

  7. For grant funding purposes:
    What is the total household income?
  8. Required:*
    By checking "yes", I certify that the information contained in this application is accurate. I Agree:
  9. Required:*
    I understand that checking this box constitutes a legal signature confirming that I acknowledge that I am the signer, and further that I agree to the above Terms of Acceptance.
  10. (Type Name)
  11. Leave This Blank:

  12. This field is not part of the form submission.