""
1
Information and Release Form
Vitals:
Child's Namefirst, last
Child's DOBdd/mm/yy
Parent's/Caregiver's Name 1first, last
Phone 1best reachable
Parent's/Caregiver's Name 2first, last
Phone 2best reachable
Emergency Contactother than parent/caregiver
Relationshipto parent/caregiver/child
Phone 3best reachable
Allergies & Medical Conditionsplease list any alleries and/or medical conditions we should be aware of; in there aren't any, please write "none".
0 /

                                                                                                      

Pickup Info:
Authorized Adult 1name of person authorized to pick up your child; first, last
Relationshipto parent/caregiver/child
Phone 4best reachable
Authorized Adult 2name of person authorized to pick up your child; first, last
Relationshipto parent/caregiver/child
Phone 5best reachable

                                                                                                      

Terms:
Please read carefully and acknowledge that you understand and agree to the terms set forth below by ticking the two checkboxes.


Release of Liability*

I acknowledge that playgroup is organized and always maintained with the students’ safety in mind, but accidents do happen.  I understand that playgroup is held outside in a public park and that my child will be participating in physical outdoor activities (incl. running & climbing), which may involve wood branches, sticks, stones and earth.


In consideration of Let's Playgroup accepting this registration and permitting the participation of the above named child in such activities, which I believe to be educational, on behalf of myself and my family, I hereby release, discharge, indemnify and hold harmless Let's Playgroup, its employees, representatives and agents from any and all claims, actions and liabilities arising out of or in connection with the above named child’s participation in any aspect of the activities provided, even in the case of Let's Playgroup's negligence.

Tuition & Payment*

A non-refundable deposit of 25% of the tuition is required and due upon execution of this agreement. The deposit will be applied towards the last month’s tuition. Tuition is payable in full at the beginning of each month.

Previous
Next