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ECHO Before- and After-School Program Registration Form

  1. ECHO Registration Form 2021-2022
  2. INSTRUCTIONS
    This form MUST be completed in its entirety. All questions must be answered. If one doesn’t pertain to your child, please write “n/a,” but do NOT leave it blank. Once this form is submitted, please call 509-498-9250 to enroll your child. Submitting the form does NOT enroll your child in ECHO. You MUST call the office to enroll. All required information must be received with complete information and have enrollment confirmed by Cheney Parks & Recreation before children may attend ECHO. A new registration form must be completed every year.
  3. only if preferred
  4. This is who we will call first in an emergency situation.
  5. Does your child have any allergies? (Please include latex, peanuts, etc.)
  6. Does your child have any special health or developmental problems or other pertinent health information?
  7. Is there anything about your child that would be helpful for us to know (fears, likes, dislikes, etc.)?
  8. Please list first and last names and phone numbers.
  9. Please list first and last names. If you are leaving blank, please put "NONE."
  10. If you or another parent/guardian changes the drop off and pickup arrangements, a written note will be required. If someone other than a listed or arranged person comes to pick up a child, identification may be required prior to the release of the child. We will NOT allow a child to walk home if the parent normally transports the child. We respectfully request that you pick up your children promptly at the end of the day. If an emergency occurs and you are unable to pick up your child, please call the Recreation Department at 509-498-9250. A late charge may be assessed and must be paid to the Recreation Department office at the Wren Pierson Community Center before the next program date, if habitual late pick-ups for a child persist.
  11. Medication Management & Emergency Medical Care Notice
    Cheney Parks & Recreation staff are unable to administer any type of medication. It is up to the parent/guardian to administer medication before or during our programs (this includes over the counter medication). As a parent or legal guardian, I authorize a licensed physician or licensed dentist to examine the above-named student; and in the event of injury, to render such emergency care as he or she deems necessary for the treatment of such injury, including consultation and treatment by a specialist, including a surgeon. As parent or legal guardian, I authorize the Recreation Department to send the above-named child to the hospital, doctor, or dentist most accessible.
  12. I agree to the above Medication Management & Emergency Medical Care Notice.*
  13. Assumption of Risk Statement
    I understand, in consideration of your accepting my child's entry, I hereby assume for myself/my child, all risks and hazards of the conduct of this City-sponsored program and release myself/my child, my heirs, executors, and administrators, any and all claims and rights for damages I/my child may have against the City of Cheney, the Cheney School District, and any participating agencies, employees, and volunteers connected with the program. I specifically hold harmless the City, its officers, officials, employees, and volunteers from and against all claims, suits, actions, or liabilities for injury or death of any person, or for loss or damage to City property, which arises out of the use of City property or from any activity, work, or thing done, in or about City property, except only such injury or damage as shall have been occasioned by the sole negligence of the City. I agree that pictures taken during program hours may be used for promotional purposes on Facebook, City website, YouTube, etc., and any other multimedia marketing tools.
  14. Coronavirus/COVID-19 Warning & Disclaimer
    ECHO has developed policies and procedures for daily operations based on state and local health departments and CDC guidelines. However, COVID-19 is an extremely contagious virus that spreads easily through person-to-person contact. Federal and state authorities recommend social distancing as a means to prevent the spread of the virus. COVID-19 can lead to sever illness, personal injury, permanent disability, and death. Participating in ECHO programs or accessing ECHO facilities could increase the risk of contracting COVID-19. Cheney Parks and Recreation and ECHO in no way warrants that COVID-19 infection will not occur through participation in ECHO programs or accessing Cheney Parks and Recreation and Cheney School District facilities. I agree to the following procedures established by Cheney Parks & Recreation Department. Please accept below. Any disagree answers will deny your child(ren) access to ECHO.
  15. I will alert ECHO if my child(ren) or anyone in our household has potential symptoms of COVID-19, such a fever, shortness of breath, chills, repeated shaking with chills, muscle or body aches, headache, sore throat, new loss of taste or smell, nausea or upset stomach, congestion or runny nose, fatigue, or diarrhea in the 72 hours prior to the start of ECHO or during the ECHO session. I understand that ECHO will deny admission to children meeting any of these criteria.
  16. I will alert ECHO if anyone in my household is diagnosed with COVID-19. I understand that ECHO will deny admission to children meeting this criteria.
  17. I understand that ECHO may need to close on short notice due to government order, child or staff illness, or other emergency. Notification will be sent via email with follow-up messaging via phone. I will maintain access to communication throughout the ECHO session.
  18. I can return to ECHO within one hour of being notified by phone if my child(ren) must be picked up.
  19. I will take my child(ren)'s temperature each morning prior to ECHO drop off and alert staff my child(ren) has a fever (temperature of 100.4 or higher). I understand that if my child has a fever of 100.4 or higher they will be denied admission to ECHO.
  20. I agree to allow ECHO staff to take my child(ren)'s temperature daily using a touch-free thermometer.
  21. I understand if my child(ren) has taken any fever reducing medications such as acetaminophen or ibuprofen in the past 24 hours they may not attend ECHO
  22. I will allow and talk to my child(ren) about wearing a mask at all times in doors and all time outdoors when social distancing is not possible.
  23. I understand that ECHO is not an educational institution and ECHO does not provide licensed teachers. Our staff will do our best to help your child with schoolwork and will ensure they are logged on to their Zoom classes, but we are not responsible for your child(ren)'s educational performance.
  24. THE FOLLOWING MUST BE COMPLETED REGARDLESS OF INCOME!
    You can upload them at the bottom of the page.
  25. EIEA Income Eligibility Form_Page_1
  26. EIEA Income Eligibility Form_Page_2
  27. Leave This Blank:

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