Request for 2022-23 SCHOOL YEAR Adventure Zone Registration

REQUEST for 2022-23 SCHOOL YEAR Adventure Zone Registration
Completion of this form does not guarantee a spot in 2022-23 ADVENTURE ZONE. The Adventure Zone Coordinator will contact you, after receipt of this form, to confirm registration for 2022-23 Adventure Zone.

Immunization Records or Exemption Form MUST be attached to registration for Adventure Zone to accept registration. By law we must have a copy your child(ren)'s immunization records or a signed and notarized exemption form on file. A child CAN NOT attend Adventure Zone without a copy on file. A photo of this document is sufficient to upload. We will not accept these forms via email or paper copies, they MUST BE uploaded with this registration form to be accepted.
Prior to completing this Adventure Zone registration form, the Adventure Zone Parent Handbook must be read, so that you understand what you are registering for along with the policies & procedures you will be required to adhere to.

Parent Acknowledgement Form must be signed below to confirm that you have read, understand and will abide by the guidelines listed in the handbook. (Handbook is available on the Becker Community Center website.)
PARENT HANDBOOK ACKNOWLEDGEMENT FORM
Name of Child(ren) you are enrolling: *
I have reviewed the guidelines in the Adventure Zone Parent Handbook, and understand the expectations for the Adventure Zone program. I understand and agree to the policies and procedures described in the handbook, including the Parent Code of Conduct and Parent Expectations/Responsibilities, as well as the Student Expectation/Responsibilities. I have discussed with my child(ren) the importance of following these policies and procedures, and that they agree to follow the rules. I acknowledge that I am liable for all fees and and charges that apply to the attendance of my child(ren) in this program. The information that I will be providing in this registration , is to the best of my knowledge, correct, and I am responsible for it accuracy. I will inform the Adventure Zone Coordinator immediately, in writing, if there are changes to the information provided from me. I have discussed with my child(ren) the importance of following these policies and procedures. I understand that abuse of these policies and procedures could result in the dismissal of my child(ren) from the program. *

Clear

Primary Parent/Guardian Information - 1ST TO BE CONTACTED *

First Name Last Name
Relationship to Child(ren) *
Home Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email Address *
example@example.com
Phone # *
Please enter a valid phone number.
Employer's Name *
Work Phone # *
Please enter a valid phone number.
Work Phone Extension (if applicable)
Parent/Guardian Information - 2ND TO BE CONTACTED

First Name Last Name
Relationship to Child(ren)
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email Address
example@example.com
Phone #
Please enter a valid phone number.
Employer's Name
Work Phone #
Please enter a valid phone number.
Work Phone Extension (if applicable)

Emergency Contacts/Authorized Pick-Up: (Emergency Contact is someone other than Parent/Guardian). If one is not provided, your registration cannot be approved. Emergency Contact is authorized to pick up child(ren), consent to medical treatment, authorize administration of medication, that we may contact in and emergency, when we cannot contact the Parents/Guardians listed above. Emergency contacts must be 18 years of age or older. It is assumed that all persons listed as emergency contacts and authorized pick-ups, are for all children listed on this form, unless parent has specified otherwise in writing.
Emergency Contact #1 *

First Name Last Name
Relationship to Child *
Emergency Contact #1 - Phone Number #1 *
Please enter a valid phone number.
Emergency Contact #1 - Phone Number #2
Please enter a valid phone number.
Emergency Contact #2 *

First Name Last Name
Relationship to Child *
Emergency Contact #2 Phone Number #1 *
Please enter a valid phone number.
Emergency Contact #2 Phone Number #2
Please enter a valid phone number.

Authorized Pick-Up Only:. Please give First and Last Name, as listed on identification, of all individuals you are authorizing to pick up your child(ren) listed above, other than Parent/Guardians or Emergency Contact(s) listed above. I understand that I am authorizing Adventure Zone to release my child(ren) to the following person(s), other than Parent/Guardian or Emergency Contact(s) listed above, anytime that they arrive for my child.
Authorized Pick-Up #1

First Name Last Name
Authorized Pick-Up #2

First Name Last Name
Authorized Pick-Up #3

First Name Last Name
Is anyone prohibited from having contact with or collecting your child?

YES NO
If "YES", who should not have permission to pick-up child?
*Please know that legally we must release a child to their parent, unless we have legal documents stating otherwise.

It is the parents' responsiblity to provide any legal documents if we are to adhere to them.
Upload Legal Documents if applicable

Cancel of
I understand that no one is allowed to pick up my child(ren) unless I have contacted Adventure Zone Staff, and signed the acceptable authorized pick-up form for the appropriate adults to pick up my child. I understand that my child will stay at Adventure Zone until I (or an adult on the authorized pick-up list) pick my child(ren) up. My child(ren) may not walk/bike home unless I have signed the appropriate permission slip. I understand that the Becker Community Center and Adventure Zone Staff are not held responsible for my child(ren) after they have been signed out.

Waiver: In consideration of my child(ren)s participation in this activity, and your accepting of my child(ren)s entry; I hereby, for myself, my child(ren), my heirs, executors and administrators, release and discharge the City of Becker, Becker Community Center, Adventure Zone and its representatives, successors, and assigns, from any and all liability arising from accident, injury, and illness that they may suffer as a result of their participation in any activity sponsored by these groups. I (we) will follow the rules and regulations set by Adventure Zone and above-named parties. Parent or Guardian must sign for anyone age 18 and under.

I have read and understand the information stated above.
Parent/Guardian Printed Name *

First Name Last Name
Parent/Guardian Signature *

Clear
Date *

Month Day Year
Date

Please tell us about Child/Children:
Are there any special circumstances that we should know about? *
Any behavioral issues that staff should be aware of? How do you handle your child/Children when s/he is being uncooperative? *
How does your child/children like to be comforted? *
Does your child/children have any specific fears that we should be aware of? *
All children need to be toilet trained and able to use the bathroom on their own. Does your child have any issues with using the bathroom or wetting that we should be aware of? *
Have there been any changes in your child's/children's life recently? (including moving, custody arrangements, death in the family, health etc.) *
How can our program best meet your families needs? *
For current families, how do you feel we are doing here at Adventure Zone?

I understand that my child needs tennis shoes, or sandals that buckle to stay on, daily, to participate in activities, and that I must provide a labeled water bottle and PM snack for my child daily. On non-school days I understand that I must provide the above, along with an AM snack and a cold lunch. If my child does not have an appropriate lunch, on non-school days, Adventure Zone will call parents and ask them to drop one off for the child by 11:00am PLEASE NOTE THAT NO NUT PRODUCTS OF ANY KIND ARE ALLOWED. *

I UNDERSTAND
I understand that Adventure Zone Staff or Lifeguards can request my child wear a lifejacket, if they feel it is necessary to keep my child safe, even if parent has marked no lifejacket above. *

I UNDERSTAND
I hereby grant permission for Adventure Zone to photograph my child(ren) and give the right to use my or my child(s) photograph or image with or without my child's name, both singly and in conjunction with other persons or objects and presentations, advertising, publicity, and promotion relating thereto. *

YES NO
*My child(ren) is allowed to watch movies rated "PG". *

YES NO
Signature *

Clear

Insurance Company Name *
Insurance Policy Number *
By signing this registration form, I am certain that, to the best of my knowledge, I have provided Adventure Zone with true and up to date contact, medical and health information, and that Adventure Zone and The Becker Community Center Staff has my permission to give the necessary first aid and/or to call for and admit my child to a medical facility for emergency treatment, if I cannot be reached. And in the event of an accidental ingestion, I understand that Adventure Zone staff will call the Poison Control Center and follow their instructions. If I am unreachable staff will contact one of my child's emergency contacts and they also have my permission to admit my child to a medical facility for emergency treatment.

I also give permission to the Adventure Zone Program Staff to take whatever emergency measures are judged necessary for the care and protection of my child(ren) while under their supervision. In case of emergency, I undersrtand that my child(ren) will be transported to an appropriate medical facility by the local emergency unit, for treatment (if the local emergency resources deem it necessary). It is understood that in some medical situations, the Adventure Zone staff will need to contact the local emergency resources before the parent, the child's physician, and/or the other adults acting on the parent's behalf are notified. I understand that any expenses incurred will be the responsibility of the child(ren)'s family.

By signing below, I acknowledge that i have read and understand the information stated above.
Printed Name of Parent/Guardian *

First Name Last Name
Signature *
Date *

Month Day Year
Date
Should be Empty:

REQUEST for 2022-23 SCHOOL YEAR Adventure Zone Registration