Jefferson Elementary After School Program (3rd-5th Grade Only)

Jefferson Elementary After School Program (3rd-5th Grade Only) - Spring 2025 Registration
Tuesdays and Thursdays
2:05 - 5:00pm
January 7 - June 3, 2025
*Adjusted hours for Parent-Teacher Conference week: 12:50 - 4:00pm
*No meetings April 1st and 3rd (Spring Recess)

Children will be picked up after school from Jefferson Elementary School and walked 3 blocks to The Game Parlour at 1342 Irving Street.

Children will have supervised homework and study time followed by free and organized play from our library of board and card games.

Please note:
- Children can bring their own snacks and drinks.
- If you have any questions, please email us at hello@thegameparlour.com.
Student Name*

First NameLast Name
Gender*
Grade*
Birthdate*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Allergies, special medical conditions or instructions of which the staff should be aware:
Parent 1 Name*

First NameLast Name
Parent 1 E-mail*
example@example.com
Parent 1 Phone Number*
Please enter a valid phone number.
Parent 2 Name

First NameLast Name
Parent 2 E-mail
example@example.com
Parent 2 Phone Number
Please enter a valid phone number.
Emergency Contacts

In the event of apparently serious illness or accident, when I cannot be reached, I wish one of the following to be notiﬁed by telephone. They are authorized to act in my absence. They may also release my child from The Game Parlour.
Name - Emergency Contact 1*

First NameLast Name
Phone Number - Emergency Contact 1*
Please enter a valid phone number.
Relationship to child - Emergency Contact 1*
Name - Emergency Contact 2

First NameLast Name
Phone Number - Emergency Contact 2
Please enter a valid phone number.
Relationship to child - Emergency Contact 2

COVID-19 PARTICIPANT RISK ASSESSMENT

I, as named parent or legal guardian of named minor (hereinafter “Participant”), hereby

1. I acknowledge that the Participant will not attend if he/she is experiencing any or all of the symptoms listed below.

(a) Fever with temperature over 98.6 degree (Please note the Participant’s Temperature may be taken with a non-touch Forehead Thermometer before entry)

(b) Cold or flu symptoms including runny nose

(c) Cough or shortness of breath

2. I understand that if at any time the Participant displays any of the symptoms listed above, they will be isolated from the program and a parent or caregiver must pick them up within the hour. No exceptions will be made.

3. I understand that should the Participant display any of these symptoms or risk factors, the Participant will not be able to return to the program for 10 days after displaying symptoms.

COVID-19 PARTICIPANT RISK ASSESSMENT FORM & LIABILITY WAIVER

I, on my own behalf and on behalf of the Participant, agree to release, indemnify and discharge The Game Parlour, its agents, officers, owners, directors, partners, employees and volunteers, on behalf of myself, my spouse, my children, my parents, my heirs, assigns, personal representative and estate as follows:

1. I understand and acknowledge that the program(s) the Participant is about to voluntarily engage in as a participant anytime they enter The Game Parlour bear(s) certain known risks and unanticipated risks which could result in illness to Participant, or to third parties.

2. I authorize medical treatment to be given to the Participant in the event of an emergency.

3. I will not hold The Game Parlour or its agents liable for injury caused by common accident, illness, or the rendering of emergency care.

4. I hereby release The Game Parlour, its officers, directors, employees, volunteers, and agents of and from any and all actions, suits, proceedings, claims, demands, assessments, judgments, damages, deficiencies, liens, penalties, fines, costs and expenses, including reasonable attorneys’ fees, resulting from, based upon, or arising out of any activity, accident or injury occurring at The Game Parlour.

5. I assume responsibility for the Participant’s behavior in adhering to all Rules of Conduct and Regulations of The Game Parlour’s After School Program. If, at the teacher’s discretion, it is decided that the Participant is unable to continue respectfully in our Program, I understand and agree that no refund will be given.

6. I give The Game Parlour permission to record my child’s image and grant all rights to use these still images for media purposes. I agree to release and hold exempt The Game Parlour from and against any claims, damages or liability arising from or related to the use of the photographs. I agree that all rights to the still images belong to The Game Parlour.

7. By signing this Agreement, I acknowledge that I have had sufficient opportunity to read this entire Agreement, I understand it completely, I understand that it affects my legal rights, and I agree to be bound by its terms.
Parent Signature*

Clear
Parent Name*

First NameLast Name
Should be Empty:

Jefferson Elementary After School Program (3rd-5th Grade Only) - Spring 2025 Registration

Emergency Contacts