After School Program 2022-2023 School Year

Student Information

Name (Nombre) *

First Name Last Name

Birth Date *

Month Day Year

Grade *

What school does your child attend? *

Student School ID# *

Gender *

Male Female

Race & Ethnicity (Mark all that apply) *

Asian White Native American/Pacific Islander American Indian Black/African American Middle Eastern Hispanic/Latino

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Shirt Size *

Youth Small (6-8) Youth Medium (10-12) Youth Large (14-16) Adult Small Adult Medium Adult Large Adult X-Large

Parent/Guardian Information

Name *

First Name Last Name

Relationship *

E-mail *

Home Number

Area Code Phone Number

Cell Number *

Area Code Phone Number

Emergency Information

Emergency Contact's Name *

First Name Last Name

Relationship *

Phone Number *

Area Code Phone Number

Alt. Phone Number

Area Code Phone Number

Participations, Release, and Medical Agreement While we make every effort to provide a safe and pleasant environment for every student who attends The Mix, we do require that this participation agreement be read, filled out, signed, and dated by all students (or their parent/guardian if under the age of 18) who wish to participate in activities at The Mix. With full knowledge, I accept full responsibility for any injury or accident that may occur to myself, my spouse, or my child while participating in The Mix activities. I give permission for my child to participate in activities that occur at The Mix. These activities may include, but are not limited to, swimming, archery, hiking, field trips, sports activities, equestrian activities, and other activities. Although The Mix has taken reasonable steps to provide equipment and skilled employees so your child can participate in activities for which he/she may not be skilled in, we do remind you that these activities are not without risk. For promotional or marketing purposes, The Mix reserves the right to use any audio, video, and/or photography of guests or campers participating at The Mix facilities. I, on behalf of my children, agree to release and hold harmless The Mix, its officers, board, agents or employees, for any and all claims for injuries, causes of action, or liability related to my child's participation in any activity occurring at The Mix. This release does not apply to intentional and/or willful acts of misconduct by The Mix or any of its officers, board, agents or employees. Should The Mix, or anyone acting on their behalf, be required to incur attorney's fees and costs to enforce this agreement, I agree to indemnify and hold The Mix harmless for all such fees and cost. By signing this document, I acknowledge that if anyone is hurt or property damaged during my child's participation in these activities, I and/or my child may be found by court of law to have waived any right to maintain a lawsuit against The Mix on the basis of any claim which has been released herein. I have had sufficient opportunity to read this entire document. I have read and understood it, and agree to be bound to its terms.

Signature

Clear

Health or Behavioral Conditions:

Drug Allergies or Other Allergic Reactions:

Dietary Needs/Restrictions:

Medication Taken Regularly:

Activity Restrictions:

I give permission for my child to attend The Mix's Afterschool Program. I understand that my personal insurance will provide primary coverage for medical aid and that The Mix will provide excess coverage. I hereby affirm that my child is in good health and physically capable of performing the required activities while at The Mix. I hereby give permission for my child to be transported to any activities outside of The Mix' building including field trips, special events & emergencies.

The staff & supporters of The Mix strive to make our environment safe and welcoming. We seek to enrich the educational, physical, and spiritual development of all students. Students play a key role in making our community welcoming, so we ask that every student agree to following the code of conduct.

*Students will treat each other and staff members with respect.

*Students will not be physically or verbally abusive to others.

*Students will not intentionally damage Arbor Place property.

*Students will not curse or use abusive language.

*Students may be removed from The Mix immediately if they are especially violent or disrespectful to students or staff.

Consequences:
1st: Student will receive a verbal warning.
2nd: Parent/Guardian will be contacted to pick up the student.
3rd: If a student is continually uncooperative, we reserve the right to withdraw them from the Summer Camp.

Preferred Hospital: *

Will your child need transportation to The Mix from their school? *

Yes No

I would like for my child to walk home at the end of the program. *

Yes No

Confirmation BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

Signature *

Clear

Any questions or comments about your registration: