2X2 Afterschool Fun

Contact: Priscilla Jones 512-618-2537 2X2kidsclub@gmail.com

Parent 1 - Primary Account Holder

First NameLast Name

Parent 1 - Primary's E-mail

example@example.com

Parent 1 - Primary's Phone Number

Phone NumberFormat: (000) 000-0000.

Primary's Address

Street Address

Street Address Line 2

CityState

Zip Code

Parent 2 - Secondary Account Holder

First NameLast Name

Parent 2 - Secondary's E-mail

(optional)

Parent 2 - Secondary's Phone Number

Format: (000) 000-0000.

Secondary's Address

Street Address

Street Address Line 2

CityState

Zip Code

Additional Authorized Check Out Person 1

First NameLast Name

Phone Number

Phone NumberFormat: (000) 000-0000.

Emergency Contact other than Primary or Secondary Account Holder

First NameLast Name

Phone Number

Phone NumberFormat: (000) 000-0000.

First Child's Name

First NameMiddle NameLast Name

First Child's Birth Date

MonthDayYear

First Child's Gender

Grade and Teacher's Name (example: 1st - Ms. Kindle)

Second Child's Name

First NameMiddle NameLast Name

Second Child's Birth Date

MonthDayYear

Second Child's Gender

Grade and Teacher's Name (example: 1st - Ms. Kindle)

Third Child's Name

First NameMiddle NameLast Name

Third Child's Birth Date

MonthDayYear

Third Child's Gender

Grade and Teacher's Name (example: 1st - Ms. Kindle)

Fourth Child's Name

First NameMiddle NameLast Name

Third Child's Birth Date

MonthDayYear

Third Child's Birth Date

MonthDayYear

Fourth Child's Gender

Grade and Teacher's Name (example: 1st - Ms. Kindle)

List below any allergies or medical concerns for your child(ren). Type N/A if not applicable

WAIVER OF ALL CLAIMS AND ASSUMPTION OF RISK

2X2 Afterschool Fun is committed to conducting all of its programs and activities in a safe manner. 2X2 Afterschool Fun holds the safety of all staff and students in high regard. Therefore, all staff members insist that students follow all safety rules. Even so, students and parents must be aware that there is an inherent risk of injury when choosing to participate in recreational and social activities. As the parent/guardian, you are solely responsible for determining if your minor child is physically, emotionally, and intellectually fit to participate in the 2X2 Afterschool Fun Kids Club Program. Also, students may be photographed or videotaped in connection with their participation in the Kids Club Program, and all claims or rights to such photos or video recordings are released by signing below. 2X2 Afterschool Fun may use these recordings and photos for any purpose that they deem appropriate.

I understand that by registering my child to participate in the 2X2 AF Kids Club Program, I am expressly assuming the risk and all legal liability that arises or may arise out of such participation. I also understand that I am waiving and releasing all claims for injuries, damages, or losses, which my child might sustain as a result of participating in any and all activities connected with and associated with said programs/activities. I recognize and acknowledge that there are certain risks of physical injury to participants in these programs/activities, and I voluntarily agree to assume the full risk of all injuries, damages, and losses, regardless of severity, that my minor child may sustain as a result of said participation except in cases of gross negligence or intentional misconduct. I further agree to waive and relinquish all claims that I, my successors, assigns, or my minor child may have (or which may accrue to me, my successors, assigns, or my child) because of participation in these programs/activities against the 2X2 Afterschool Fun, its owners, directors, staff, volunteers, employees, and associated companies. I do hereby fully release and forever discharge 2X2 Afterschool Fun from all claims for injuries, damages, or loss that my minor child may have or which may accrue and arising out of, connected with, or in any way associated with these programs/activities, except in cases of gross negligence or intentional misconduct

By signing the box below and submitting this form I am registering my child for the Kids Club Program. I understand that this is a faith-based program, that it is my discretion to enroll my child in this program, and I have read and agree to the terms and conditions above regarding my child’s participation in the program. I also understand that my child will be expected to conform to the 2X2 Afterschool Fun Kids Club Program code of conduct and if s/he does not, I will be notified, and they may be removed from the 2X2 Afterschool Fun Kids Club Program.

Signature

Enrollment Fees & Payment

Enrollment | One Student

$275 One Student plus $10 Processing Fee | Processing Fee is non refundable

$285.00 for each month

Enrollment | Two Students

$275 for 1st Student, $245 for 2nd Student plus $10 Processing Fee | Processing Fee is non refundable

$530.00 for each month

Enrollment | Three Students

$275 for 1st Student, $245 for 2nd Student, $235 for 3rd Student plus $10 Processing Fee | Processing Fee is non refundable

$765.00 for each month

Enrollment | Four Students

$275 for 1st Student, $245 for 2nd student, $235 for 3rd Student, $235 for 4th Student plus $10 Processing Fee | Processing Fee is non refundable

$1,000.00 for each month

2X2 KIDS CLUB

Enrollment Fees & Payment