Kids Form

Form
Kids Program Registration Form
Which Program are you registering for?
Parent/Guardian #1 Name*

First NameLast Name
Parent/Guardian #1 Email*
example@example.com
Parent/Guardian #1 Home Phone*
Please enter a valid phone number.
Parent/Guardian #1 Work Phone*
Please enter a valid phone number.
Parent/Guardian #2 Name

First NameLast Name
Parent/Guardian #2 Email
example@example.com
Parent/Guardian #2 Home Phone
Please enter a valid phone number.
Parent/Guardian #2 Work Phone
Please enter a valid phone number.
Student's Name*

First NameLast Name
Student's Birthday*

MonthDayYear
Date
Student's Grade Level*
Student's Pronouns*
Student's Medical Conditions and Allergies*
Second Student's Name

First NameLast Name
Second Student's Birthday

MonthDayYear
Date
Second Student's Grade Level
Second Student's Pronouns
Second Student's Medical Conditions and Allergies
Emergency Contact Name*

First NameLast Name
Emergency Contact Number*
Please enter a valid phone number.
Physician's Name*

First NameLast Name
Physician's Contact Number*
Please enter a valid phone number.
Alternative Authorized Person to pick up the child:

First NameLast Name
Phone Number
Please enter a valid phone number.
I, First Name Last Name , the parent and or guardian of First Name Last Name minor, authorize my child to go home on their own.
Yes/No

YesNo
Signature

Clear
Today's Date

MonthDayYear
Date

Afterschool Program
Which Session/Day are you registering your child for?
Will your child require pickup?

YesNo

Afterschool Program Pick up
If you have not already paid for the pickup option, please click this sentence to register your student for it.
Student's Name*

First NameLast Name
Student's Pronouns*
Student's Birthday*

MonthDayYear
Date
School*

Brooklyn ArborPS 84NorthsideOther (This is a request, we will only be able to establish pickup to other schools if there is enough expressed interest)
Grade*
Classroom*
Teacher*
School Contact Number*
Please enter a valid phone number.
School Email*
example@example.com
Time of Pick-up*
Designated Pick-up Location*
Special Directions/Instructions
- I understand that I must notify Choplet Ceramic studio before 11am if my child is not attending school and/or will not need to be picked up. I will also alert the school and the teacher.
- I understand that my child must follow the directives of the supervising staff members at dismissal. Failure to follow safety policy and procedures will be ground for termination of my child's participation in the pick-up services offered by Choplet Ceramic Studio. I understand that only (1) warning will be issued before my child is expulsed from the service, due to safety concerns. I understand that if my child is expulsed from the service, I must arrange alternative pick up and it does not entitle me to a refund of the program’s tuition.
- I understand that if my child is attending PS110, pick up will be arranged by taxi van or personal car and I am responsible for providing a car seat.
- I waive and release the Company, its employees and its contractors from any claim for personal injury, property damage or death that may arise during transportation of my child from the school to Choplet Ceramic Studio.
I First Name* Last Name* have read, understand and agree to the above.
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date

I, First Name* Last Name* , the parent and or guardian of First Name* Last Name* minor, knowing the risks involved in ceramics, including wheel throwing, hand building with tools, voluntarily sign this waiver and assumption of risk in favor of Choplet Design sur Grand (the Company) for the opportunity to have my child pursue the creation of ceramic art and/or to receive instruction from the Company’s employees and/or contractors. I waive and release the Company, its employees and its contractors from any claim for personal injury, property damage that may arise from my use of the facilities or from my child’s participation in the activities or instruction. In the event the child named above is injured or ill, I understand that Choplet Studio will attempt to contact me, the other parent, or the legal guardian associated with this registration. In the event that I or the others listed on my child’s registration are not available or that the emergency is such that EMS must be contacted first, I give my permission for Choplet Ceramic Studio’s staff to take the appropriate measures including contacting the emergency medical services (EMS) system and arranging for transportation to the nearest medical facility. I agree to pay all fees and costs arising from the action to obtain medical treatment. I also give permission for attending physician(s) or other medical personnel to administer any needed medical treatment, including surgery and I agree to pay for the medical treatment.

If my child is displaying any cold symptoms despite testing negative for Covid-19 (sneezing, coughing, sore throat, runny nose), I agree to send them to the afterschool program with a mask to wear for the duration of the class.

I understand that there are certain risks and dangers associated with the activity and use of the facilities and that these risks have been fully explained to me. I fully understand the dangers involved.

I fully assume the risks involved as acceptable to me and my child has the ability to exercise judgment in undertaking these activities and follow all safety instructions. I authorize Choplet Studio to photograph or film myself and/or my child without compensation, as well as the ceramic work produced, for the use in the studio’s promotional efforts.

I have read and accept the policies of Choplet studio and the social distancing and hygiene guidelines that will be implemented for the full duration of the classes. I further understand and accept that if my child cannot follow instructions within these guidelines, I will be contacted to pick them up. I understand that Choplet Studio reserves the right to cancel a class as a result of insufficient enrollment. I am aware that a $100 non-refundable deposit is required to register and hold a spot in a class and the balance will be refunded to me if I provide the cancellation in writing, no later than 7 days prior the first day of class. No refunds available is available thereafter. In the event the after-school session has to be interrupted under the directive of CDC guidelines, I understand that Choplet will convert from in-person to online instruction and I will not receive a refund or a credit.

I understand the studio provides a 10 minutes grace period for late pick up and that my credit card on file will be charged $15 per 20 minutes of late pick up afterwards.
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Form

Kids Program Registration Form

Afterschool Program

Afterschool Program Pick up