Game On Youth Registration 2025

Game On Youth Registration

Game On Youth is a unique table top gaming club for neurodivergent youth. Learn more by visiting our website: www.gameonyouth.com
Child Information
Child's Name*

First NameLast Name
Birth Date*

MonthDayYear
Grade Level in 2025/2026*
Gender*

MaleFemaleNon-BinaryPrefer Not to Say
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Information
Name*

First NameLast Name
Home Number
Cell Number*
E-mail*
example@example.com
Emergency Information
Emergency Contact's Name*

First NameLast Name
Relationship*
Phone Number*
Alt. Phone Number
Does your child have any allergies, chronic illness, or medical conditions? If yes, please describe.
Does your child need any accommodations in order to participate? If yes, please explain.
Is there anything else we need to know in regards to your child?
***Transitions Program ONLY***

If your child is participating in the Transitions Program, please check this box

Transitions Program Participation Agreement

By registering my child for the Transitions Program at Game On Youth, I acknowledge and agree to the following terms:
- Support Person Requirement – Participation in the Transitions Program requires that my child be accompanied by a designated support person unless an alternative arrangement has been pre-approved by Game On Youth. The support person should be someone familiar with my child and their specific needs.
- Attendance Contingency – I understand that if my child’s designated support person is unavailable, my child may not be able to attend the program that day.
- Notification Responsibility – If my child’s support person is unavailable for a scheduled program day, I agree to notify Game On Youth via email at brandi@gameonyouth.com as soon as possible.
- Support Personnel Policy – I acknowledge that Game On Youth does not provide or train support personnel. It is my responsibility to arrange for an appropriate support person who is equipped to assist my child as needed. Game On Youth will collaborate with families and support personnel to ensure participants receive necessary accommodations within the program’s structure.
- Billing and Insurance – I understand that Game On Youth does not bill insurance and does not engage in activities for which a super bill could be provided. All program fees are the responsibility of the family and must be paid directly to Game On Youth.
Agreement:*

By checking this box I acknowledge I have read and agree to the above policies

Policies
Illness Policy

Any child exhibiting the following symptoms should stay home until all symptoms have been relieved for 24 hours. A doctor’s release is required to return to the center following a communicable disease.

Exclusion is required when a participant has:
- Fever of 100 degrees F or higher, taken underarm
- Runny nose that is yellow or green in color
- Cough with yellow-green phlegm
- Rashes on the body, except diaper rash
- Diarrhea (loose, watery, foul smelling bowel movements)
- Vomiting
- Conjunctivitis (pink eye)
- Impetigo (skin infection)
- Strep Throat
- Lice
- Chicken Pox
- Ringworm
- Positive covid test in the last 5 days
If staff notices any of the symptoms above, we will contact you immediately and terminate the session.
Attendance and Absence Policy

I understand that, in the event of a missed event due to any reason, make up sessions are not provided. Late arrivals will be permitted to join, but understand that, due to the nature of this camp, important information may be missed if arriving late.

I understand that in the event I am going to be late for pick up, I will inform the instructor by phone. I understand that being more than 15 minutes late will result in a $10/minute fee, no exceptions. After more than 3 late pick ups, my child will not be allowed to participate.
Refund and Deposit Policy

All registrations include a non-refundable $75 deposit in order to hold your place in the camp.

All cancellations must be made in writing and sent to brandi@gameonyouth.com and are subject to the following refund policies:
- Cancellations made within 2 days of registration will be refunded in full, deposit included.
- Cancellations made 3 weeks prior to the start of a session will be refunded at 80%, minus the deposit.
- Cancellations made 2 weeks prior to the start of a session will be refunded 50%, minus the deposit.
- Cancellations made less than 14 days prior to the start of a session will not be refunded.
Exclusions to the refund policy:
- Cancellations due to medical or emergency circumstances - a written notice of cancellation with explanation of medical or emergency circumstances must be provided for a refund request to be considered. Additional documentation may be requested. Partial or full refunds for medical or emergency circumstances will be at the discretion of Game On Youth.
- Covid-19 - Refunds in full will be offered to families who have tested positive for Covid-19. Additional documentation may be requested.
- Inclement weather - in the event a session needs to be cancelled by Game On Youth due to inclement weather, an attempt will be made to hold a virtual social gaming session. If this is not possible (such as during a power outage) a full refund for the affected session amount will be provided to families in the form of a discount in a future session
- Staff unavailable - in the event Game On Youth is unable to staff a session, a full refund for the affected session amount will be provided to families
- Cancelled session - in the event a session does not meet the minimum number of required participants, it will be cancelled and participants who do not opt to transfer to another camp will be refunded in full.
Agreement:*

By checking this box I acknowledge I have read and agree to the above policies

Medical Release and Authorization

As Parent and/or Guardian of the named child, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.

Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named athlete. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me.

Permission is also granted to Game On Youth and its affiliates to provide the needed emergency treatment prior to the child’s admission to the medical facility.

Release authorized on the dates and/or duration of the registered event.

This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.
Primary Physician's Name*

First NameLast Name
Physician Phone Number*
Insurance Information*

CompanyMember ID
Agreement:*

By checking this box I acknowledge my agreement with the medical release and authorization above
Photo Release

I grant permission to Game On Youth, its agents, and its employees the irrevocable and unrestricted right to produce photographs and video taken of my child for any lawful purpose including publication, promotion, illustration, advertising, trade, or historical archive in any manner or in any medium by Game On Youth. I hereby release Game On Youth and its legal representatives from liability for any violation or claims relating to said images or video. I waive my right, my child’s rights, and my family’s rights to any and all compensation stemming from the use of these materials.
Agreement (choose one):*

By checking this box I AGREE with the photo releaseBy checking this box I DO NOT AGREE with the photo release. Pictures of my child may not be taken.
Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by Game On Youth during the selected club. In exchange for the acceptance of said child’s candidacy by Game On Youth, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Game On Youth and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected club sessions.

In case of injury to said child, I hereby waive all claims against Game On Youth including all therapists and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event.
Agreement:*

By checking this box I acknowledge my agreement with the informed consent and acknowledgement above
Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

By typing your name below, you are electronically signing this document, signifying your agreement to the terms outlined herein, and this typed name shall be considered equivalent to your handwritten signature.
Parent/Guardian Signature*

First NameLast Name
Date*

MonthDayYear
Date
Signature*

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ONE LAST THING!!

In order for your child to attend, you will need to fill out this registration form AND submit your payment before your spot is secured. We have limited spaces available, so don't delay in completing this form and submitting your payment here if you haven't already:

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And don't forget to click submit below!!!
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Game On Youth Registration

Child Information

Policies