Clone of Elite Cheerleading Registration Form

Parent Note:

Early Learning Coalition Parents must still pay their weekly fee along with additional fees pertaining activities.

Annual Physical

Participant Name*

First NameLast Name

Date of Birth*

Date

Age

School

Grade Upon Enrolling

Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

ResidentNon-Resident

FemaleMaleN/A

T-Shirt/Jersey Size

Parent/Guardian Name*

First NameLast Name

Relation

Cell Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Alternative Number

Please enter a valid phone number.Format: (000) 000-0000.

Parent Email*

example@example.com

Insurance Card

Please upload the front of insurance card

Provider & Insurance Policy Number:

Emergency Contact*

First NameLast Name

Relation

Emergency Contact Cell Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Emergency Contact Email

example@example.com

CHILD AUTHORIZED for PICK-UP (18 & over other than parent)

First NameLast Name

Relationship

CHILD AUTHORIZED for PICK-UP (18 & over other than parent)

First NameLast Name

Relationship

CHILD AUTHORIZED for PICK-UP (18 & over other than parent)

First NameLast Name

Relationship

PARTICIPANT HOLD HARMLESS: As a condition of participation in this program, the undersigned agrees that in the event of disablement injury or diseases of a temporary or permanent nature incurred by the participant while in the program, that all claims or liabilities are waived against the City of Riviera Beach Recreation and Parks Department, City of Riviera Beach, Florida and/or employees thereof and the undersigned does hereby assume said risk as one of the ordinary risks of participation in said program, and consequently holds the City of Riviera Beach harmless in the event of disablement injury or disease named by the undersigned in the program. PARTICIPANT BEHAVIOR: Additionally, violent behavior WILL NOT BE TOLERTED. Any participant who engages in inappropriate behavior will be escorted from the program and suspended from a minimum of three (3) scheduled games.

Signature*

Date*

Date

Register and pay for all youth and adult classes/activities in person at the Parks and Recreation Department located at 2499 Ave H West Riviera Beach Fl., 33404 (keep copies of all documents for yourself. Enrollment for classes/ programs/camps fills quickly, so please register early. MUST submit copies of ORIGINAL Birth Certificates, Annual Physical and Insurance Information as required by the programs you register for. Complete refunds will be issued if class is cancelled. Full and partial refunds are issued according to the refund policy stated below. For registrations done in person, you may make payments by CASH/CREDIT/DEBIT CARD/MONEY ORDER only – NO CHECKS. Please make money orders payable to the City of Riviera Beach. Form must be completed in its entirety using ink only; all information is required at time of registration. No incomplete registration will be taken; there will be no pending files.

REFUND POLICY:

-Administration fee before class starts is $15.00 or 15% whichever is less

-No Refund will be issued if notified after the session has begun. (All Programs)

-Please allow 4 to 6 weeks before refund is mailed to you.

(Must return original receipt to P&R Admin. Office. Mailing address and contact phone number must be indicated on back of receipt)

CITY OF RIVIERA BEACH - PARKS AND RECREATION

1621 West Blue Heron Blvd., Riviera Beach, FL 33404

Phone: (561) 845-4070 Email: Parks@rivierabeach.org

Office Hours: Monday - Friday: 8:30 AM to 5:00 PM

SPRING BREAK CAMP INFORMATION & RULES

Each participant MUST wear sneakers. Open-toed shoes, flip flops, or sandals are not permitted. Wells Campers are required to bring a blanket/ towel for nap time and a change of clothes.
The office telephones will be available for emergency call only.
All problems or complaints should be filed with the Camp Director. Abusive language, profanity, and any violent physical contact (fighting) will not be tolerated from either participants or counselors. Severe offenses will result in termination from the program. We do reserve the right to impose a written warning, mandatory parental/guardian conference, or up to a 5-day suspension if the offense is not considered severe.
Misconduct on field trips will result in a suspension from all further trips. If a participant is suspended from camp during the week of a scheduled trip, he/she will not be allowed to attend any field trips that week. NO REFUNDS will be given for paid trips.
All materials, clothing, or items brought to the facility by your child should be labeled. We are not responsible for any materials or electronics that are left at the facility, trips, buses/vans. Toys and personal items should be left at home. Spring Break Camp is not responsible for damaged or lost items.
Breakfast and Snack is provided for all Spring Break Camp participants. Some Field Trips will include lunch and some will not. Please make sure that to pay close attention to the itinerary however, If you choose to provide breakfast / lunch for your child, please have it there by: Breakfast (8:00am-9:00am) & Lunch (12:00pm-1:00pm).
All field trips will be limited to a first come, first serve basis! Refunds will not be issued for participants that miss the bus for scheduled trips. All trips must be paid prior to the scheduled trip date. No trips can be paid for the day of the field trip.
It is mandatory for all participants to wear their Spring Break Camp T-shirts for all trips.
Spring Break Camp ends at 6:00pm each day. Participants need to be picked up no later than 6:00pm. An initial late fee of $5.00 will be charged for the first 15 minutes after 6:00pm. In addition, there will be a charge of $1.00 per minute thereafter. The late fee must be paid at the Parks and Recreation Administration Office by the following day or suspension from program will occur.
NO REFUNDS will be given for ANY SPRING BREAK CAMP RELATED FEES, (i.e, registration, aftercare, field trips).

I have read the Spring Break Camp Rules and agree to the terms listed.

Signature

Date

Spring Break Camp Payment

New Camp Member Registration Fee

$100.00

Total

$0.00

Payment Methods

Debit or Credit Card

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

The City Of Riviera Beach Spring Break Camp Registration

Please complete all required fields*

Parental/Guardian Consent