ActivKids – Online Registration Participant Form

I hereby authorize the School District to release to the Park District and WDSRA the following information relating to the Student: student record information relating to the Student’s behavior, interventions, and accommodations. This information may be released verbally or in writing, by the School District and/or any of the School District’s employees, to the Park District’s ActivKids program Administrators and/or to WDSRA’s program Administrators. Each program Adminis-trator is hereby authorized to share verbal information with appropriate program staff, in the Administrator’s discretion. The Carol Stream Park District and WDSRA are required to maintain the confidentiality of student record information, to prohibit unauthorized re-disclosures of such information, and to use such information only for purposes relating to the Student’s participation in the programs. In addition, I hereby authorize the Carol Stream Park District and WDSRA to release to each other and to the School District (and/or any of their employees) the following information relating to the Student: Information relating to the Student’s participation in WDSRA programs and Park District ActivKids programs, and information relating to the Student’s behavior, interventions, accommodations, services and activities in those programs. This information may be released verbally or in writing. This release/exchange and sharing of information is authorized for the purpose of determining appropriate services and ac-tivities for the Student, and to help the staff of the three agencies provide safe and successful Student experiences. I understand that I have the right, upon request, to inspect, copy and challenge the contents of school student records prior to release, and the right to limit any consent for the release of school student records to designated records or designated portions of information in school student records. I also understand that I have the right to revoke this consent, in writing, at any time. I certify that I am the Parent or Guardian of the above named Student, who has not yet reached the age of 18, graduated from secondary school, married or entered into military service. Any copy of this consent shall be considered as valid as the original. This consent is valid until August 1, 2020.

Indicate below any information you feel would benefit Carol Stream Park District staff. Lack of detailed information compromises the staff’s ability to successfully accommodate your child. Carol Stream Park District is not responsible for any injuries, complications, damages or losses due to lack of information provided. Many resources and adaptations are available to assist your child; please keep us informed.

Parents/Guardians with custody have authorization to pick up the participant. List siblings, parents without custody, relatives, or friends who are also authorized to pick-up your child. All individuals must present a photo ID in order for your child to be released into their custody. Only the custodial parent(s) may approve additions or changes to the Authorized Contact and Release List.