2017 UHS AFTER PROM REGISTRATION FORM ALL UHS Junior and Senior students are invited to attend the UHS After Prom Party on Saturday, May 20th ~ Admission is FREE ~ It is not necessary to attend the Prom to go to the After Prom You may choose to have a parent pick you up at 3:00 a.m. or leave at 5:00 a.m. Sunday, 5/21.

IMPORTANT: Every attendee of After Prom (students and guests) must complete an individual registration form. A guest is a non-UHS student or a UHS Freshman or Sophomore. If you are attending with a guest, your guest and their parent must complete and sign all areas where indicated on their own form. A list of students and guests registered for the After Prom will be posted on the PTO page of the UHS website as registrations are received. Questions? Contact Jen Horne at [email protected] or cell phone (302) 740-0320. Complete both sides of the form, and return by May 8th to Denise Avayou at 1149 Dorset Drive, West Chester, PA 19382 or hand deliver to the UHS After Prom box in the UHS Main Office.

ATTENDEE INFORMATION Name: ______________________________________

Grade: ____________ Cell#____________________________

STUDENT email: ______________________________PARENT email:_______________________________________ *****Parent contact numbers for night of event: Cell:______________________ Home:_____________________***** I am a (circle one):

UHS JR / SR

NON-UHS Student

UHS Freshman / Sophomore

If you are a guest, name of person you are attending with: ______________________________________________ Arrival time for the After Prom Party is between 11:00 p.m. and midnight. Parents will be called if a registrant does not sign in by midnight.

Medications for the After Prom Prescription and non-prescription medication for the After Prom must be supplied by the parent / guardian in the ORIGINAL CONTAINER and must be turned over to the nurse at the After Prom at check in. To minimize the medications needed during the event, every effort should be made to administer medications before or after the After Prom. Students may carry certain emergency medications (i.e., EpiPen, inhalers, insulin) if they have approval to carry them during regular school hours. Please indicate if your student will be bringing medication to the After Prom: YES _______ NO _______ If YES, please indicate medication(s):_____________________________________________________________________________ If your child has any medical issues that you think the After Prom nurse should be aware of, please check here_______ and the nurse will contact you to discuss. AT THE END OF AFTER PROM IT IS THE STUDENT’S RESPONSIBILITY TO COME TO THE NURSE AND PICK UP THEIR MEDICATIONS.

Scott Honda Car Giveaway A car will be raffled off to one lucky UHS Junior or Senior student during the After Prom. ONLY UHS Juniors and Seniors attending the After Prom are eligible to win the car. ** STUDENT MUST BE PRESENT TO WIN** The drawing will occur between 4 a.m. and 5 a.m. on May 21st. Please note that the winner of the car and their parents are responsible for paying any monies, including but not limited to taxes, title, insurance, etc., incurred as a result of winning the car. The car will be available for pick up the week following the After Prom. I hereby give consent for my child ____________________________ to be entered to win the car donated by Scott Honda at the UHS After Prom Party and sign below. _____________________________________/______________________________________________/_______________________ Parent / Guardian Signature Printed Name Date

Hypnotist Release The After Prom will feature a hypnotist entertainer who will engage with students selected at random from the audience who have completed this consent. The attendees without written permission are invited to be part of the general audience. I hereby give consent for my child _________________________________ to participate in the Hypnotist entertainment at the UHS After Prom Party. _____________________________________/______________________________________________/_______________________ Parent / Guardian Signature Printed Name Date

Bump N Play Release Please complete the enclosed Bump N Play waiver if you consent for your child to participate in Bump N Play (www.bumpnplay.com). THE WAIVER MUST BE RETURNED WITH THIS REGISTRATION FORM.

AFTER PROM CONSENT ARRIVAL / DISMISSAL PROCEDURES The intent of the After Prom Party is to keep students safe and off the roads on Prom night. The party is a school-sanctioned event that runs from 11 p.m. on May 20, 2017 until 5 a.m. on May 21st, with an option for students to leave at 3 a.m. SCHOOL RULES APPLY. POLICY, PROCEDURE & LIABILITY RELEASE for attendee and parent(s): I understand the purpose of the After Prom is to keep students safe and by my signature below, I agree that my child will remain at the After Prom until the departure time of 5 a.m. OR until I or an alternate adult authorized below picks up my child at 3 a.m. For attendees leaving at 5 a.m., the After Prom Committee strongly urges parents to pick up their students, as opposed to the students driving themselves home. Neither the Unionville High School PTO, the Unionville-Chadds Ford School District, nor any individual associated with either organization shall be liable for any claim of any sort whatsoever that arises out of anyone either attending or traveling to or from the Unionville High School After Prom Party. - Students must arrive by midnight. Parents will be called if students do not sign in. - Unless authorized below, students will be dismissed at 5 a.m. - It is strongly suggested that parents transport students home from the After Prom at 5 a.m. - I have noted above if my child will be carrying medication or has other conditions that the nurse should be made aware of for the night of the event. - Dismissal of a student that is not consistent with the registration form will only occur in the case of illness or other unforeseen issue at the After Prom Party, which requires the After Prom nurse or security personnel to request early student dismissal. - Students leaving prior to 5 a.m. for any reason, are not eligible to win the Scott Honda car.

PLEASE COMPLETE THIS SECTION ONLY IF YOUR CHILD IS LEAVING AT 3 A.M. - 3 a.m. dismissal requires parents to present a valid form of identification for student release. - I understand that if my child leaves early, they may not be re-admitted to the After Prom. - I understand that my child may only be picked up by me, with a valid form of identification, or by the adult authorized below, with a valid form of identification. My child ________________________________ will be leaving the After Prom at 3 a.m. and I will be picking them up

OR

I authorize the following adult to pick up my child from the After Prom at 3 a.m. on May 21st. Name: _______________________________

Cell #:_______________________ Email: _________________________________

I UNDERSTAND THE DISMISSAL POLICY AS DESCRIBED AND AGREE TO ABIDE BY IT:

_____________________________________/______________________________________________/_______________________ Parent / Guardian Signature Printed Name Date

_____________________________________/______________________________________________/_______________________ Student / Attendee Signature Printed Name Date