Night Owl's Kid's Only Night
This program is on select Friday nights from 6-10 p.m. This event includes a pizza party dinner, themed games, and indoor facility play.
Child's Information
Child's Name
*
First Name
Last Name
Birth Date
*
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Day
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Year
Gender
*
Male
Female
Date:
Tuesday, February 14, 2023
Friday, March 3, 2023
Friday, April 7, 2023
Friday, May 5, 2023
Parent/Guardian Information
Parent/Guardian #1
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Number
*
E-mail
*
example@example.com
Parent/Guardian #2
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Number
*
E-mail
*
example@example.com
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Approved Pick Up Person #1
*
First Name
Last Name
Approved Pick Up Person #1 Driver's License Number
*
Approved Pick Up Person #1 Phone Number
*
Please enter a valid phone number.
Approved Pick Up Person #2
*
First Name
Last Name
Approved Pick Up Person #2 Driver's License Number
*
Approved Pick Up Person #2 Phone Number
*
Please enter a valid phone number.
Does the child have any allergies, chronic illness, or medical conditions?
*
Yes
No
If yes, please explain:
I give permission to Kidtopia to allow my child to participate in all activities planned for the evening, as well as eat the pizza and desert served for the evening. I understand that it is required of me to inform the Kidtopia staff of any food allergies, physical disabilities, or any other conditions before participation in the event.
*
Agree
I understand that Kidtopia's Night Owl's Program is a kid's only event. I knowingly and willing leave my child in the care of the Kidtopia staff during the duration of the event.
*
Agree
I knowingly and voluntarily assume all risks involved in my child's participation and do hereby release Kidtopia, and its members, trustees, officers, employees, independent contractors, and agents from any and all liability, damages, costs, and expenses arising out of or relating to bodily or psychological injury, loss of life or personal propery that may occur as a result of participating in this program, regadless of cause.
*
Agree
I understand that participating in activities, facility play, climbing walls, indoor and outdoor play equipment, inflatable obstacles, slides, and all excursion plans entail certain risks. Those risk can include increased heart rate, blood pressure, strained or sprained muscles, fractured bones, partial or complete paralysis, heart attacks, psychological injury, death, or possibility of any other serious injury. I elect to allow my child to participate in any and all activities in spite of these risks.
*
Agree
I understand Kidtopia's Night Owl's Kid's Only Event is an active program with physically challenging activities available for student participation. *
*
Agree
I understand that my child may be photographed and photos may be used in media publications that would represent Kidtopia and its program in a positive manner.
*
Agree
I understand that bad language and behavior that is disruptive, disrespectful, and/or aggressive will not be tolerated and further agree that dismissal of my child is at the discretion of the Program Director.
*
Agree
My child and/or I have read, understand and accept the terms and conditions stated herein and acknowledge that this agreement shall be effective and binding upon the parties during the entire period of participation in the program.
*
Agree
Kidtopia has permission to secure emergency transportation for my child in the event of an illness or injury which requires emergency treatment. The emergency transportation service will determine the facility to which my child will be transported.
*
Type First and Last name above to consent
Sign Enrollment Agreement
*
Date Signed
*
-
Month
-
Day
Year
Date
Submit
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