Tots and SpOTs Play Group Registration Sept/Oct 2024

Tots and SpOTs Play Group Registration and Release (September 26th - October 17th 2024)

Please fill out one registration/release form and purchase one ticket ($100) for EACH child ages 1-3 you wish to have participate in Tots and SpOTs.
Child's name*

First NameLast Name
Child's Date of Birth:*

MonthDayYear
Child's age as of 9/26/24*
Allergies (please include type of reaction)
Medical Precautions and/or Adaptive Equipment Needs
Is your child currently receiving any therapeutic services (OT, PT, Speech, etc.). If so, please specify.

In Case of Emergency...
Primary contact in case of emergency*

First NameLast Name
Primary emergency contact phone number*

Area CodePhone Number
Primary contact email address*
example@example.com
Secondary contact in case of emergency*

First NameLast Name
Secondary emergency contact phone number*

Area CodePhone Number
Our policy is to call 911 in the case of any medical emergency. Please indicate if you would like us to do otherwise, and what action you would like taken:
In the case of an emergency, it is likely that your child will be transported to Newton-Wellesley Hospital. If you prefer that your child be taken to a different hospital or facility, please indicate below.
I do hereby assume full responsibility for any and all damages, injuries, or losses that I may sustain or incur, if any, while attending or participating in any facility exercise program, sport or physical activity at the Boston Ability Center. I hereby waive all claims against, its instructors, or partners of the program, individually or otherwise, for any and all claims for injuries or damages that I might sustain.

I understand that there is risk of injury associated with participating in any facility exercise, program, or sports activity. I certify that I am in good physical condition and have no known disabilities that might otherwise be detrimental to my health or well-being. I certify that all of the information provided on this application is correct and true to the best of my knowledge.

All applicants must sign. Parents or guardians must sign if applicant is UNDER 18.
Signature of Parent/Legal Guardian:*

Clear
Name of Parent/Legal Guardian:*

First NameLast Name
Date:*

MonthDayYear

Photo and Video Consent Form

(optional)
I hereby grant The Boston Ability Center permission to use my child’s likeness in a photograph or video in any and all of its publications, including website entries, without payment or any other consideration. I understand and agree that these materials will become the property of The Boston Ability Center and will not be returned. I hereby irrevocably authorize The Boston Ability Center to edit, alter, copy, exhibit, publish or distribute photos or videos for purposes of publicizing The Boston Ability Center’s programs or for any other lawful purposes. In addition, I waive the right to inspect or approve the finished product, including written or electronic copy, wherein the likeness of my child appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of photographs or videos. I hereby hold harmless and release and forever discharge The Boston Ability Center from all claims, demands, and causes of action which I, my heirs, representatives, administrators, or any other persons acting on my child’s behalf may take.
Parent/Guardian Signature

Clear
Parent/Guardian Printed Name
Date

MonthDayYear
Date

Payment
Please indicate your understanding with the following by signing your initials in the spot provided.*

Please select ticket type:

5-week Session (9/26-10/17)$100.00

Drop In Session$25.00

1 drop-in session permitted per family

Enter coupon

Total $0.00

Please indicate date of drop-in session you wish to attend:*

MonthDayYear
Date

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.

Should be Empty:

Tots and SpOTs Play Group Registration and Release (September 26th - October 17th 2024)

In Case of Emergency...

Photo and Video Consent Form

Payment