Patriot Club Registration Form 2024/25

PLEASE READ THE ENTIRE FORM

NOTE: Your student will not be eligible to attend Patriot Club until their registration is processed

(Please allow 1-2 buisness days to process new registrations. You will receive a welcome letter once your registration is processed)

Student Information

Students Name*

First NameLast Name

Birth Date

MonthDayYear

Student's Grade and Teacher *

Age*

Gender*

MaleFemale

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

1) Parent/Guardian Information

Name: *

First NameLast Name

Relationship*

Phone Number*

Please enter a valid phone number.

Cell Number

Please enter a valid phone number.

Email*

example@example.com

2) Parent/Guardian Information (Optional)

Name:

First NameLast Name

Relationship:

Home Number

Cell Number

E-mail

example@example.com

Emergency Information

Emergency Contact's Name*

First NameLast Name

Relationship*

Phone Number*

Alt. Phone Number

People authorized to pick up student other than you (Include Name, Relationship, Phone Number)(EXAMPLE: Jane Doe/Mother/(509)432-6543)

Does the student have any allergies, chronic illnesses, or medical conditions? If yes, please describe.

Is the student prescribed an inhaler and/or Epipen? If yes, please explain any instructions.

Informed Consent and Acknowledgement I hereby give my approval for my child’s participation in any and all activities prepared by LCS Patriot Club during Club hours. In exchange for the acceptance of said child’s candidacy by LCS Patriot Club, I assume all risks and hazards incidental to the conduct of the activities, and release, absolve and hold harmless LCS Patriot Club and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from club activities. In case of injury to said child, I hereby waive all claims against LCS Patriot Club, including all coaches and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event. There is a risk of being injured that is inherent in all sports activities, including basketball. Some of these injuries include but are not limited to the risk of fractures, paralysis, or death.

Full Name of Parent/Legal Guardian *

First NameLast Name

Signature of Parent/Legal Guardian*

Medical Release and Authorization As Parent and/or Guardian of the named student, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed. Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named athlete. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me. Permission is also granted to the LCS Patriot Club and its affiliates, including Directors, Coaches, and Team Parents, to provide the needed emergency treatment prior to the child’s admission to the medical facility. The release is authorized on the dates and/or duration of the registered session. This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.

Full Name of Parent/Legal Guardian *

First NameLast Name

Signature of Parent/Legal Guardian*

Patriot Club guidelines and information

(By signing below you agree to these guidelines)

All families planning to use Patriot Club must first fill out and submit registration forms online. One per student.

Students may attend ONLY after their registration paperwork has been processed. Processing registration paperwork may take up to two business days. Patriot Club is offered on a first-come, first-served basis, and spaces may be limited.

Patriot Club is open to LCS students: Age 5 (K4 included) - 6th grade

HOURS & LOCATION:

August 28th-June 11th, Monday-Friday.

Before-school 6:30a-7:45a Club meets in the MPR at LCS.

After-school 2:55p-5:30p Club meets at First Baptist Church

DAYS WE ARE CLOSED: Patriot Club will be closed during Thanksgiving, Christmas, and Spring breaks. Patriot Club will not be offered during the afternoons on Grandparents Day and the Last day of school. The school calendar has these coded as Red, Yellow and Green dates.

Aug 19th-23rd, 26th and 27th We are closed in preperation for the new school year.

DAYS WE ARE OPEN: Patriot Club will be offered to all registered students during in-services, grading days, and conferences for an additional charge and will require payment at least two weeks in advance. Additional details will be provided at least a month ahead of time. The school calendar has these coded as Purple, Light blue, and Blue dates.

PRICING:

Registration...$65.00/student > Paid online with registration

Hourly Fee.....$10/hour > Billed every 15 min. Minimum 1-hr fee (after school only)

Students will not be admitted into the Clubhouse before 6:30 am

Patriot Club ends at 5:30 pm each day. A late charge of $1/minute will be levied for any student not picked up by 5:30 pm.

Patriot Club uses the RenWeb check-in/Check-out time for official purposes.

STUDENT SCHEDULE:

Each student must complete an attendance form before their first day of care. Set schedules and drop-in schedules are available. After the student's registration is processed, you will receive more information in the welcome letter.

CHANGES TO SCHEDULE:

For the safety of the students and for staffing purposes, parents/guardians are required to communicate ANY attendance changes directly to Patriot Club Director no later than 1:59 PM on the day of change through the TeamReach app. This includes: Sickness, field trips, vacation etc.

Note: The LCS office does not communicate these changes to Patriot Club. The parent/guardian is responsible for communicating these changes directly to Patriot Club.

Note 2: Changes to attendance can be communicated through TeamReach in advance and is reccomended if known in advance.

NO SHOW (PM Care only): A no show fee of $10.00 (1-hr fee) will be levied if changes are not communicated via TeamReach before 1:59 pm on the day of care.

Student lists are finalized by 2:01 pm day of care.

TEAMREACH:

Club communications will be through the app TeamReach and is required before the first day of care. You will receive TeamReach information in our welcome letter once registration is processed, 1-2 buisness days.

EMERGENCIES Can not pick up by 5:30pm: If an emergency arises and you cannot pick up your child by 5:30 pm, you must contact the staff through the TeamReach app or the Club Cell Phone to assure both the staff and your child that you are on the way. State law requires us to notify CPS when children are left in a program without notification from families and when no contacts can be reached to pick up the child.

These guidelines are followed in response to late pick-up:

1. Staff notifies the family and/or emergency contacts to ensure that someone is on the way to pick up the child.
2. If the family and emergency contacts cannot be reached, the child will remain with staff on campus at a $1/minute surcharge.
3. As state law requires, if parents and emergency contacts are not reached, the school will be required to call the police.

Contact the Club Director Cat Isley, with any questions or concerns. cisley@libertychristian.net

Patriot Club Payment Policy

LCS Patriot Club requires sufficient funds be available in the students Patriot Club pre-pay account prior to the day they are planning to attend.

Misuse of the Patriot Club pre-pay account as an invoicing system or paying after care has been provided will result in suspension from the program.

FACTS Prepaid account balance reports are run daily and notifications will be sent out on Mondays.

(1) Any Patriot Club pre-pay account with a negative balance exceeding -$20.00 will be sent a notification and a warning on Mondays.

(2) Any Patriot Club pre-pay account with a negative balance exceeding -$20.00 two weeks in a row, will be sent a 2nd warning and the student(s) will be suspended from Patriot Club for 1 week, effective the following business day.

(3) Any Patriot Club pre-pay account with a negative balance exceeding -$20.00 three weeks in a row, will be sent a notification and the student(s) will be suspended from the Patriot Club program for the remainder of the year.

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.

Full Name of Parent/Legal Guardian *

First NameLast Name

Signature of Parent/Legal Guardian*

My Products*

Patriot Club Registration Fee 2023/24

$65.00

Total

$0.00

Payment Methods

Debit or Credit Card

First Name

Last Name

Credit Card Number

Security Code

Card Expiration

Please click one of the PayPal options to complete payment and submit the form.

LCS Patriot Club Registration Form