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Please complete form and return to one of the following locations on or before Monday, October 18th:
Front Office or Mrs. Adamson (Room 313)
Participant’s Name: _____________________________________________
Grade: ______
Parent Phone Number:________________________
(Number we can reach you at between 2:45pm – 3:45pm):____________________
Parent Email: _________________________________________________
Signature of Parent/Guardian_______________________________________
Date_____________________________
Waiver: In consideration of my child’s participation in this activity, I hereby release and discharge South Middle School and all persons connected with the activity from any and all liability arising from illness, injury and damage my Child may suffer as a result of participation in the activity. I also understand I am responsible for any cost incurred for medical services or illness, injuries and damages to my child while participating in the activity.
Quarter #2 Activity Choices
Directions: Rank the following activities in order from 1-5 with 1 being the activity you would like to do the most. Depending on the number of students, we will do our best to get you into your top 3 choices. You will hopefully get to do 3 activities for 2 weeks each. You will receive a schedule prior to the start date of session #1 for the entire quarter.
______ Basketball @ Salina Fieldhouse
______ Volleyball @ Salina Fieldhouse
______ Soccer @ Salina Fieldhouse
______ Dodgeball @ Salina Fieldhouse
______ Bowling @ The Alley
*Ride MUST be able to pick up at this location at 3:45pm
_______ Taekwondo @ SMS
_______ Soccer @ SMS
_______ Board games @ SMS
*Ride MUST be able to pick up at this location at 3:45pm
Name: ________________________________________