Game Club Student Registration for Madison Schools

How did you hear about Game Club?

The SchoolA friendOther

Student's Name*

First NameMiddle NameLast Name

Please Verify that you are registering a student for the Mansfield Christian School Game Club. (If not, please note that there are different forms for each school)*

Mansfield Christian School (5th - 12th graders) - Meets Mondays from 3:30-5:00 PM (March 17 & 31 April 7 & 28 May 5 & 19)

Please verify student's school.

Madison High School - Meets Tuesdays from 2:30 - 4:30 PMMadison Middle School - Meets Thursdays from 2:30-4:30 PMMadison South Elementary (3rd and 4th graders) - Meets Fridays from 3:30-5:00 PM

Student's Information*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parent/Guardian # 1*

Email Validator (non-urgent updates)*

Parent/Guardian # 2

Take Photo

Email Validator (non-urgent updates)

Is there a custody arrangement or dispute regarding your child? If yes, please explain anything that might effect pick-up of your child. *

How will the student be getting home from club?*

Picked upWalking

What is the student's favorite game(s)

What game(s) would they like to learn?

Name of Emergency Contact - Most be somone other than you.*

First NameLast Name

Phone Number*

Relation to Student*

Confirmation*

I hereby declare that I give my full express consent to let my child be given immediate treatment by any qualified medical personnel in circumstances which may need immediate attention and care.

Any know Allergies to food?*

Does your child have any health/behavioral conditions or physical/mental limitations we should be aware of?*

Is there anything else you feel we should know?*

* To the best of my knowledge, the information contained in this form is accurate.

Participation Consent and Comment

The above-named child has my permission to attend Game Club each week. (There will be no club on days without school.)

I agree to the following:

To provide and update contact information for myself and my emergency contacts
To save the phone #'s of the Game Club Team leaders on my phone.

Director: Jadaé Fox # 419-545-4783
Team Leader: Eric Byrom # 567-241-6338
To ensure that my child gets picked up on time after Game Club
To contact a club Team leader ASAP if there is a delay

I understand that failure to pick up my child on time may jeopardize their continued participation. Furthermore, club leadership must arrange transportation with the authorities if I (or my emergency contacts) cannot be reached within 30 minutes of the club's end.

Waiver

I, the undersigned, understand that while precautions are taken to ensure safety, there are always risks associated with any physical activity, including, by way of example, physical injury due to activity-related accidents, illness (including, but not limited to, COVID-19, MRSA, influenza, and other infectious or communicable diseases), or even death. In addition, I acknowledge that there may be other risks inherent in these activities of which I may not be presently aware. By signing this form, I expressly assume all risks related to participating in the activities, whether such risks are known or unknown to me at this time. I release and agree to indemnify and hold harmless Games Reach and its employees, volunteers, and agents from any and all claims arising from participation in its activities and programs.

Photos/Videos may be taken at the club. Please check the box below if you DO NOT give permission to have your child's photograph taken.

Signature*

Parent / Guardian*

First NameLast Name

Donations support the programing of Games Reach a 501c3 Nonprofit EIN 92-3436703. Checks can be sent to Games Reach 365 Straub Rd. E. Mansfield, OH 44903. Find more ways to give @ https://gamesreach.org/donate/ (copy and past in another tab)

USDWe give a yearly tax receipt. Thank you for your support!

Payment Methods

Debit or Credit Card

Choose from one of the PayPal options to make your payment.

2024-25 - Game Club Student Registration - Mansfield Christian School

General Information

Emergency Contact Information

Medical Information

Game Club Rules

Parental/Guardian Consent and Waiver

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