Participant Enrollment Form
Complete this form to enroll in our program and provide necessary participant and guardian details.
Participant Information
Participant Legal Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Age
*
Gender
Please Select
Female
Male
Non-binary
Prefer not to say
Other
Medical conditions, allergies, or accommodations
Guardian Information
Parent/Legal Guardian Full Name
*
First Name
Middle Name
Last Name
Relationship to Participant
*
Please Select
Parent
Legal Guardian
Grandparent
Other Relative
Family Friend
Other
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Secondary Emergency Contact Name
*
First Name
Middle Name
Last Name
Secondary Emergency Contact Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Program Selection
Program Enrolled
*
Please Select
Open Play
Weekly Enrichment
Creative Arts
Film & Media Lab
Birthday Package
Membership
Session Start Date
-
Month
-
Day
Year
Date
How did you hear about us?
Please Select
Website
Social Media
Friend or Family
Search Engine
Flyer or Poster
Event
Other
Agreements
I have read and agree to the Enrollment Agreement
*
I agree
I have read and agree to the Liability Waiver and Assumption of Risk
*
I agree
I have read and agree to the Program Terms and Attendance Policy
*
I agree
I have read and agree to the Payment Agreement and Billing Terms
*
I agree
I acknowledge that Care Bear Playhouse, LLC is a non-custodial enrichment program
*
I acknowledge
Media Release
*
GRANT authorization
DECLINE authorization
Authorized Pickup Contacts
Authorized Pickup Contact 1 Name
*
First Name
Last Name
Authorized Pickup Contact 1 Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Authorized Pickup Contact 2 Name
First Name
Last Name
Authorized Pickup Contact 2 Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Digital Signature
Guardian full legal name
*
First Name
Middle Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: