Code N' Create JES Afterschool STEM Registration and Parent Agreement

Code N' Create Afterschool STEM Registration and Parent Agreement

Complete this form once for each child before the child's first session. Update Code N' Create if contact, medical, or pickup information changes. Sessions are Mondays and Wednesdays from 3:30 to 4:30 PM at James E. Sampson Memorial, 3201 Memory Lane, Fort Pierce, Florida. The program serves students in grades 3 and up and costs $15 per session.
Student information
Student full name

First NameLast Name
Date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Grade
School or homeschool
First planned session date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Regular attendance
Parent or guardian information
Parent or guardian full name

First NameMiddle NameLast Name
Relationship to student
Mobile phone
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Home address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Second parent or guardian name and phone
Financially responsible adult, if different from the parent completing this form
Emergency and support information
Emergency contact full name
Emergency contact relationship
Emergency contact phone number
Please enter a valid phone number.Format: (000) 000-0000.
Allergies (food, medication, environmental, or other)
Medical conditions, dietary needs, accommodations, or support instructions
Emergency care instructions, if any
Does the child need medication during the session?
Authorized pickup
Photo permission
Choose one. Photo permission is optional and does not affect participation.
Photo permission
My child may be released only to a parent, legal guardian, or authorized adult listed on this form. If an unfamiliar adult will pick up my child, I will call Code N' Create in advance. The adult must present matching photo identification and sign the child out. My child will remain with staff until pickup is verified.
Authorized adult 1 full name

First NameMiddle NameLast Name
Authorized adult 1 relationship to student
Authorized adult 1 phone number
Please enter a valid phone number.Format: (000) 000-0000.
Authorized adult 2 full name

First NameMiddle NameLast Name
Authorized adult 2 relationship to student
Authorized adult 2 phone number
Please enter a valid phone number.Format: (000) 000-0000.
Authorized adult 3 full name

First NameMiddle NameLast Name
Authorized adult 3 relationship to student
Authorized adult 3 phone number
Please enter a valid phone number.Format: (000) 000-0000.
Authorized adult 4 full name

First NameMiddle NameLast Name
Authorized adult 4 relationship to student
Authorized adult 4 phone number
Please enter a valid phone number.Format: (000) 000-0000.
I acknowledge and agree to the pickup authorization policy above.
Program activities and participation
Code N' Create provides a one-hour STEM enrichment session using rotating activities that may include coding and game design, robotics, electrical engineering, science projects, STEM fidget toy creation, board games, and STEM activity cards. Homework help may be available as needed. Activities vary by session and may involve small parts, tools, electronics, moving equipment, and ordinary hands-on classroom risks. Students must follow staff instructions and safety rules.
I acknowledge and agree to the program activities and participation terms above.
Snacks and allergies
Families should send water and a snack. Students may not share food or drinks. Packaged snacks should remain in their original packaging so ingredients can be checked. Parents must disclose food allergies and emergency instructions before attendance. Code N' Create will communicate specific food restrictions when needed but does not promise an allergen-free environment.
I acknowledge and agree to the snacks and allergies policy above.
Payment and cancellation agreement
Payment is a weekly or monthly subscription through Square: $30 per week or $110 per month. Code N' Create will send a Square subscription signup link after this registration is received. Choose weekly or monthly billing at checkout. Subscriptions are ongoing and can be cancelled at any time. There is no refund or make-up session for a missed session. If Code N' Create cancels a session, the family may choose a refund, move the payment forward, or retain it as account credit.
I acknowledge and agree to the payment and cancellation policy above.
Pickup and late fee agreement
Pickup is by 4:30 PM. A five-minute grace period is provided. Beginning at 4:36 PM, a late fee of $1 per minute per family applies. Call or text 772-301-9257 if delayed. Repeated late pickups may affect continued enrollment.
I acknowledge and agree to the pickup and late fee policy above.
Behavior policy
Students must follow safety instructions, respect people and equipment, use appropriate language, and remain in assigned program areas. Code N' Create will contact the parent or guardian about serious or repeated behavior concerns. Conduct that creates an immediate safety risk may require early pickup or removal from the program.
I acknowledge and agree to the behavior policy above.
Emergency authorization and signature
If I cannot be reached during an emergency, I authorize Code N' Create staff to call emergency services and provide responders with the information on this form. I understand that this authorization does not permit Code N' Create to provide nonemergency medical treatment or administer medication without separate written authorization.
I acknowledge and agree to the emergency authorization above.
Typed parent or guardian full name

First NameMiddle NameLast Name
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
I certify that the information is complete and accurate and that I am authorized to register this child.
Should be Empty:

Code N' Create Afterschool STEM Registration and Parent Agreement

Student information

Parent or guardian information

Emergency and support information

Authorized pickup

Photo permission

Program activities and participation

Snacks and allergies

Payment and cancellation agreement

Pickup and late fee agreement

Behavior policy

Emergency authorization and signature