The Spot Activity Center Registration Form

The Spot Activity Center Registration Form
Activity:
Child(ren)'s Name:
Birthday(s):
Family Information
Mother's Name:
Mother's Cell #:
Format: (000) 000-0000.
Mother's Work #:
Format: (000) 000-0000.
Mother's Email:
example@example.com
Father's Name:
Father's Cell #:
Format: (000) 000-0000.
Father's Work #:
Format: (000) 000-0000.
Father's Email:
example@example.com
Address:
Emergency Information
Emergency Contact Name:
Emergency Contact Phone #:
Format: (000) 000-0000.
Relationship to Child:
Allergies:
Medications:
Other Important Information:
Persons NOT Allowed to pick up Child:
Agreement
The above information is true to the best of my knowledge. I understand that I am financially responsible for any balance that may accrue. I am aware that The Spot Activity Center is NOT a childcare center and is NOT licensed by DHR as such but, rather, is an ACTIVITY CENTER meant for my child/children's entertainment and enrichment. If utilizing the Pick-Up Service, PRES has been notified that my child/children will be meeting at the school trail and will be leaving the school property with The Spot representatives. I authorize The Spot Activity Center to call 911 in the event my child/children require(s) immediate medical attention.
Parent/Guardian's Signature:
Date:

MonthDayYear
Date
Should be Empty: