A Flow Code Afterschool Program 2023

"*" indicates required fields

If you have any questions or problems filling out this form, please email [email protected] or give us a call at (703) 675-2323
Name of Participant*
MM slash DD slash YYYY
Does the participant have a sibling enrolled in the program?
Name of Parent/Guardian*
What is the best way to contact you?*
Name, Contact number, Relationship to Camper
Name, Contact Number, Relationship to Camper
Is the participant taking medication to treat a physical condition?*
* If yes, a physician's note and medication list will need to be provided if medication is required during sessions
* We ask this so that we can be sure we are able to best serve our participants and have adequate staff on hand if special attention is needed. In no way will this affect whether your child is able to participate.
Medical Treatment Authorization*
In case of emergency, accident, illness, or other incapacity occurring while under Aflo's authority, I give my permission for the participant to be treated by medical professionals and admitted to the hospital if necessary. This authorization applies whether or not the charges are covered by my insurance, and I am responsible for all medical and emergency expenses.
Media Release*
I authorize Aflo Health, Inc. staff to take audio, video and photographic recordings of this participant. Aflo Health, Inc. shall own all rights to recordings and photographs, to be used and disposed of at the discretion of the Aflo Health, Inc. Audio, video and photos are primarily used for brochures & flyers, and on our website. Participant names are never used without explicit parent/guardian consent; you will be contacted by a staff member before any names are used.