SNUMA Participation Form

Southern Nevada Urban Micro Academy (SNUMA)
Participation Form

Please add at least one child

Children

Southern Nevada Urban Micro Academy (SNUMA)
Participation Form

Parent / Guardian #1 Information

Last Name

First Name

Email Address This email address will be used for communications from the City of North Las Vegas

Primary Phone Number

Secondary Phone Number

Address

Employer Name

Essential Employee or First Responder?

Yes

Parent / Guardian #2 Information

Last Name

First Name

Email Address

Primary Phone Number

Secondary Phone Number

Address

Employer Name

Essential Employee or First Responder?

Yes

Southern Nevada Urban Micro Academy (SNUMA)
Participation Form

Authorized People to Pick Up Child

Individual picking up child will need to show ID. Please add at least one authorized person.

Emergency Contact

Authorized Person(s)

Southern Nevada Urban Micro Academy (SNUMA)
Participation Form

Assurances – All must be checked to be eligible. I hereby acknowledge that:

Each child must be SIGNED IN (AM) and/or SIGNED OUT (PM) daily by an AUTHORIZED PARENT/GUARDIAN or EMERGENCY CONTACT listed on this participation form. *

CUSTODY AGREEMENTS: The City of North Las Vegas, and SNUMA are not able to interpret or make rules relating to custody agreements. This is the responsibility of the custodial parties and the City nor SNUMA will neither negotiate nor mediate custody arrangements. The City nor SNUMA will not be responsible for enforcing time constraints relating to visitation. *

For ourselves, and on behalf of our child named above, our heirs, executors, and administrators, we hereby do expressly, and forever waive and release the City of North Las Vegas, Nevada Action for Choice Access dba Nevada Action for School Options, and all their respective officers, employees, agents, or representatives from all liability for personal injuries or damage sustained, incurred, arising from, or connected with travel to, return from, and all classes, tournaments, and other activities undertaken in connection with the Academy and the recreation program offered before and after the Academy.

Signature

Print Name

Date

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SNUMA Participation Form

Parent / Guardian #1 Information

Parent / Guardian #2 Information

Authorized People to Pick Up Child