After-School Kids Club Registration

Child Name*

First NameLast Name

Date of Birth*

Date

Grade Level*

Parent or Guardian Name *

First NameLast Name

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Does your child have any allergies that we should be aware of?*

Does your child have any medical conditions that we should be aware of?*

Does your child qualify for Free/Reduced Lunch?*

YesNo

Emergency Contact *

First NameLast Name

Emergency Contact Phone Number*

Please enter a valid phone number.

Relationship*

I give permission to my child, blanks* ,(child name) permission to attend and participate in activities sponsored by Kids at Their Best. I hereby release Kids at Their Best, its employees, associates, and contributors from liability from any injury, loss, or theft incurred by my child while participating. Furthermore, I hereby authorize medical examination and emergency treatment for my child by emergency personnel in the event of an accident. I further understand that Kids at Their Best has an "Open Door" policy, which means that my child may come and go at will. I further understand that doors to the After-School Kids Club close at 5:15 pm. I understand that Kids at Their Best is not utilizing its own building and need to be respectful of the time that they were allotted to use the school. Furthermore, I understand that no Kids at Their Best staff will be present past 5:15 pm. My signature below indicates that I completely understand the above statement.

MEDIA RELEASE: I give permission to have my child's photos used in Kids at Their Best publications, social media, news articles, marketing materials, etc.*

YesNo

When will be your child's first day attending our program?*

Date

By signing up your child for After-School Kids Club, it is assumed that they will be attending from Monday-Thursday. If there is ever a day that they cannot stay, the parent/guardian is responsible for calling Green Acres and letting them know that their child will not be attending programs that day.*

I understand that I am responsible for calling Green Acres on days when my child cannot attend After-School Kids Club.

Signature*

After-School Kids Club Registration

Disclaimer