Inscription Pizza/Fruit Larchmont 2015-16 - French

Inscription Pizza/Fruit Larchmont 2015-16 L’école ne fournissant pas de repas chaud les lundis, FASNYPTA propose aux élèves de Larchmont un service de pizza accompagné d’un fruit frais. Rappelons que le programme pizza du lundi a pour objectif de servir un déjeuner hebdomadaire aux élèves tout en recueillant des fonds pour FASNYPTA.
Pour inscrire vos enfants (campus de Larchmont uniquement), merci de bien vouloir remplir
ce formulaire, signer la décharge de responsabilité au verso de cette page et joindre votre
règlement. Vous devez déposer votre inscription au bureau de Larchmont dans la boîte FASNYPTA,
nous l’envoyer par courrier (111 Larchmont Avenue, Larchmont, NY 10538) avant le vendredi 11
septembre ou l'apporter lors du forum info du 11 septembre.
Merci de bien vouloir noter que nous ne pourrons pas accepter les demandes de remboursement au cours de l'année scolaire.
NOM DE FAMILLE : ADRESSE EMAIL : TELEPHONE : Prix annuel (15 Sept– 15 Juin) Nom de l’enfant Classe 1 part fromage $121 2 parts fromage $194 Chèque à l’ordre de FASNY-­‐‑PTA – chèque # _____ ou Cash PAIEMENT TOTAL: ________________ Si vous souhaitez aider au programme Pizza, veuillez contacter Carine Le Garrec à
[email protected]. Merci!
WAIVER AND RELEASE OF LIABILITY FOR PARTICIPATION IN THE PIZZA SERVICE PROGRAM
Student’s Name: ___________________Date of Birth:_________________
Permanent Address:_____________________________________
City:__________________ State: ____________ Zip: ________
Phone No. (Home) _______________ (Cell) _______________ Email ____________________
To be completed by Parent/Legal Guardian for Student.
THIS DOCUMENT INCLUDES A WAIVER AND RELEASE OF LEGAL RIGHTS. PLEASE READ
CAREFULLY BEFORE SIGNING.
We authorize our child, __________________________, (“Student”) to participate in the Pizza Service Program
sponsored by the French American School of Ne w York Parent Teacher Association (“FASNYPTA”). In consideration
for Student’s participation the program, we agree to release FASNYPTA and the French American School of New York
(“FASNY”), as described m ore fully below, and, on behalf of ourselves as parents, the Student, and Student’s heirs,
personal representatives, guardians, successors, and assigns, agree to the following terms:
1. We hereby unconditionally, irrevocably and absolutely release, discharge and agree to indemnify and hold harmless
FASNYPTA and FASNY, and their respective board of trustees, employees, agents, drivers, attorneys, insurers,
divisions, chaperones, successors and assignees, from any and all loss, liability, claims, demands, causes of
action, settlements, costs or expenses (including attorneys’ fees), dam ages or suits of any type, whether in law
and/or in equity, related directly or indirectly, or in any way connected with Student’s participation in the
program.
2. We further agree to forever discharge, release and/or waive any and all rights, liabilities, claims, demands, actions
executions and/or judgments with respect to any allergic reaction, food poisoning, medical treatment or other
ailments relating to, or arising from, or out of, directly or indirectly, the Student’s participation in the program.
3. We understand and acknowledge that should the Student sustain or incur any accidents or illness (including an allergic
reaction) while participating in the program, we understand that FASNYPTA or FASNY will immediately contact
the appropriate emergency response unit for medical assistance. We also authorize FASNYPTA or FASNY to act
in its best reasonable judgment to minimize further harm to Student while awaiting the arrival of medical
assistance.
4. We hereby authorize FASNYPTA or FASNY to execute any and all documents, including necessary releases, which
might be required by any medical facility to perform any emergency care to Student.
5. We represent that Student is covered by adequate health and accident insurance necessary to cover any and all medical
costs or other costs that m ay be incurred as a result of or that m ay arise out of Student’s participation in the
program. We agree to pay for any costs related to the medical treatment or other costs not covered by the medical
or accident insurance.
6. WE ACKNOWLEDGE THAT WE HAVE CAR EFULLY READ THIS AGREEMENT AND FULLY
UNDERSTAND ITS CONTENTS. WE ACKNOWLEDGE THAT WE ARE VOL UNTARILY EXECUTING
THE AGREEMENT OF OUR OWN FREE WILL AFTER HAVING HAD THE OPPORTUNITY
TO CONSULT WITH LEGAL COUNSEL OF OUR OWN SCHOOSING WE ACKNOWLEDGE AND
UNDERSTAND THAT THIS AGREEMENT RELEASES THE FRENCH AMERICAN SCHOOL OF NEW
YORK PARENT TEACHER ASSOCIATION AND THE FRENCH AMERICAN SCHOOL OF NEW YORK
AND OTHERS DESCRIBED ABOVE FROM ANY AND ALL LIABILITY IN CONNECTI ON WITH ANY
INJURY OR DAMAGES OR LOSSES OF ANY NATURE SUFFERED AS A RESULT OF STUDENT’S
PARTICIPATION IN THE PROGRAM DESCRIBED ABOVE, AND WAIVES ANY CLAIM FOR, AMONG
OTHER THINGS, DAMAGES, FEES AND EXPENSES, AND/OR ATTORNEYS’ FEES. WE AGREE AND
UNDERSTAND THAT THIS AGREEMENT BINDS ALL MEMBERS OF STUDENT’S FAMILY, ESTATE,
HEIRS, ADMINISTRATORS, PERSONAL REPRESENTATIVES AND ASSIGNEES.
7. WE REPRESENT THAT WE ARE STUDENT’S ____PARENTS/____ GUARDIANS, AND ARE FULLY
COMPETENT TO SIGN THIS AGREEMENT. WE EXECUTE THIS AGREEMENT FOR FULL, ADEQUATE
AND COMPLETE CONSIDERATION AND FULLY INTEND FOR STUDENT, US AS PARENTS JOINTLY
AND SEVERALLY, AND FOR STUDENT’S FAMILY, ESTATE, HEIRS, ADMINISTRATORS, PERSONAL
RE PRESENTATIVES AND ASSIGNEES TO BE BOUND BY THIS AGREEMENT.
Mother/Guardian Name (please print): ________________________________________
Signature:____________________________________
Father/Guardian Name (please print):___________________________________________
Signature:____________________________________________
Student’s Name (please print): ________________________________________
Emergency Contact (print name) ________________________________________
Home Address: _________________________________________________________
Home Phone ________________________
Work Phone ________________________
Cell Phone _________________________
E-Mail____________________________________
Relationship to Minor Student:______________________________________________