Annual Waiver & Medical Authorization Form

Alliance Française de San Diego — 2026–2027 School Year

Please complete this form once per child, per school year, before their first class. It replaces the paper form previously signed via DocuSign. Fields marked with * are required.

1. Student Information

Student First Name *
Student Last Name *
Date of Birth *
Grade / Level (2026–2027)
School Currently Attending (if applicable)

2. Parent / Guardian Information

Parent / Guardian First Name *
Parent / Guardian Last Name *
Relationship to Student *
Email Address *
Mobile Phone *
Address
City
State
ZIP code
Country

3. Emergency Contacts (other than parent/guardian above)

Emergency Contact 1 — Name *
Emergency Contact 1 — Relationship *
Emergency Contact 1 — Phone *
Emergency Contact 1 — Authorized for Pick Up and Drop Off *
Emergency Contact 2 — Name
Emergency Contact 2 — Relationship
Emergency Contact 2 — Phone
Emergency Contact 2 — Authorized for Pick Up and Drop Off
Emergency Contact 3 — Name
Emergency Contact 3 — Relationship
Emergency Contact 3 — Phone
Emergency Contact 3 — Authorized for Pick Up and Drop Off

Authorized Pick-Up List

If you plan to have someone other than yourself or your authorized emergency contacts listed above pick up your child from our camps, workshops, or classes, please add them to this form. If we do not have written permission, we will not release your child to any individual not listed as an emergency contact or for authorized pick-up. Those picking up the child, including parents, must show photo identification. If you find, after the start of the school year, that you would like to authorize an additional person to sign your child out, please provide written permission for the release of the child to that individual.

Only the individuals listed below or in the emergency list are authorized to pick up my child. All must show a valid photo ID.

Persons Authorized to Pick Up My Child (other than parent/guardian and emergency contacts above)

Pick-Up & Late Fee Policy

I understand that classes, camps, workshops, and extended care programs end promptly at their scheduled times. If I or an authorized adult arrives more than 15 minutes late to pick up my child, I agree to pay a $25 late fee for each 15-minute increment.

AFSD reserves the right to contact emergency services if a child is not picked up and no contact can be established after an hour.

4. Guidelines Acknowledgment

I confirm my child:

Is potty trained
Will come with a refillable water bottle (for camps only)
Will wear weather-appropriate, closed-toe shoes (for camps only)
Will bring lunch if staying past noon (for camps only)

5. Medical Information & Authorization

Allergies (food, medication, environmental, etc.)Write 'None' if no known allergies.
Current MedicationsWrite 'None' if not applicable.
Medical Conditions We Should Be Aware Of (asthma, epilepsy, diabetes, etc.)Write 'None' if not applicable.
Health Insurance Provider
Policy / Member ID
Family Physician / Pediatrician
Physician Phone

Medical Authorization

I hereby authorize the Alliance Française de San Diego and its staff to obtain emergency medical treatment for my child in the event I cannot be reached. I understand that I am financially responsible for any medical treatment provided. I release and hold harmless the Alliance Française de San Diego, its employees and volunteers from any liability arising from the administration of such emergency care.

I agree to the Medical Authorization above *

6. Waiver of Liability & Assumption of Risk

On behalf of myself and my child, I waive and release the Alliance Française de San Diego, its officers, directors, employees, teachers and volunteers from any and all claims, demands, causes of action and liability for any injury, loss or damage arising out of or connected with my child's participation in classes, workshops, events and activities, whether on or off premises. I understand that participation involves certain inherent risks, and I assume those risks on behalf of my child.

I have read and agree to the Waiver of Liability & Assumption of Risk *

7. Photo & Media Release

I grant the Alliance Française de San Diego permission to photograph and/or record my child during activities and to use such images in publications, website, social media and promotional materials.

Photo & Media Release *

8. Signatures

Parent / Guardian Signature *Sign with your mouse or finger.
Sign Here
Printed Name of Parent / Guardian *
Student Signature (adult students 18+ only)
Sign Here
Date Signed

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