Guardian Name *

First Name

Last Name

Guardian Phone *

(###)

###

####

Emergency Contact *

If the guardian listed above cannot be reached, who can we contact in the event of an emergency?

First Name

Last Name

Emergency Contact Phone # *

(###)

###

####

I understand that this Study Hall space is sponsored by PvilleYI and Smokey Row, and is not sponsored by Pleasantville Community School District. If I have questions I understand that I should contact PvilleYI or Smokey Row, not the school. *

Yes

Do the following students have permission to attend the Study Hall at Smokey Row? *

NOTE: This is NOT a School sponsored event. This event is hosted by Pleasantville Youth Initiative and Smokey Row.

Yes

No

Do the following students have permission to sign themselves out and leave when the session they are attending ends, or do they need to wait for a guardian to come in and sign them out? *

Students can sign themselves out.

Students must wait for a guardian to sign them out.

I agree that if any of the following students have fevers or other symptoms of illness, or if they have been exposed to Covid-19, I will notify PvilleYI and NOT SEND them to the Study Hall. *

Space is limited. If your student can't come for any reason, please contact us right away and let us know so we can open up space for other students.

I agree

Which sessions did you confirm attendance with PvilleYI? *

08/31- 9am-11am

08/31- 1pm-3pm

09/01- 9am-11am

09/01- 1pm-3pm

09/02- 9am-11am

09/02- 1pm-3pm

09/03- 9am-11am

09/03- 1pm-3pm

09/08- 9am-11am

09/08- 1pm-3pm

09/09- 9am-11am

09/09- 1pm-3pm

09/10- 9am-11am

09/10- 1pm-3pm

Student 1 Name *

First Name

Last Name

Student 1 Phone

(###)

###

####

Student 2 Name

First Name

Last Name

Student 2 Phone

(###)

###

####

Student 3 Name

First Name

Last Name

Student 3 Phone

(###)

###

####

Student 4 Name

First Name

Last Name

Student 4 Phone

(###)

###

####