Student Enrollment & Release Form: A Kids Gym

NON-INGESTIBLE OVER THE COUNTER (OTC) MEDICATION AUTHORIZATION FORM

A Kids Gym Learning Academy
Childs Name*

First NameLast Name
Today's Date*

MonthDayYear
Date
DOB*

MonthDayYear
Date
I GIVE PERMISSION FOR THE FOLLOWING NON-INGESTIBLE OVER THE COUNTER MEDICATIONS (MARK ALL THAT APPLY)*

DIAPER RASH CREAMS/OINTMENTSINSECT REPELLENTSUNSCREENCORTISONE/ANTI-ITCH CREAMSOTHER NON-INGESTIBLE OTC'S PLEASE SPECIFY BELOWN/A
OTHER NON-INGESTIBLE OTC'S I GIVE PERMISSION FOR (THAT IS NOT LISTED ABOVE)
TO ADMINISTER A NON-INGESTIBLE OVER THE COUNTER (OTC) MEDICATION:
- THE OTC MEDICATION MUST BE BROUGHT TO THE FACILITY FROM THE PARENT
- THE OTC MEDICATION MUST BE IN ITS ORIGINAL CONTAINER, WITH A LEGIBLE LABEL, AND EXPIRATION DATE OF MEDICATION
- THE CHILD'S NAME MUST BE LEGIBLE AND ON THE ORIGINAL CONTAINER
WE DO NOT ADMINISTER TYLENOL OR MOTRIN.
REFRIGERATION REQUIRED?

YesNo
Signature*

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THIS DOCUMENT MUST BE UPDATED ON AN ANNUAL BASIS

FAMILY HANDBOOK
PLEASE CLICK HERE TO DOWNLOAD OUR FAMILY HANDBOOK.
I have downloaded the AKGLA Family Handbook. I have reviewed and accept all policies stated within the document. I agree to abide by the policies set forth in the AKGLA handbook. I have received and understand the discipline/disenrollment policy at AKGLA, which is outlined in the Family Handbook.*

I ACCEPT
KNOW YOUR CHILDCARE
PLEASE CLICK HERE TO DOWNLOAD THE KNOW YOUR CHILDCARE FACILITY HANDOUT
A Kids Gym has provided me a copy of the Child Care Facility Brochure, "KNOW YOUR CHILDCARE FACILITY" published by the Department of Children and Families.*

I RECEIVED AND ACCEPT
DISTRACTED ADULT HANDOUT
PLEASE CLICK HERE TO DOWNLOAD THE DISTRACTED ADULT HANDOUT
A Kids Gym has provided me a copy of the Child Care Facility Brochure, "DISTRACTED ADULT" published by the Department of Children and Families.*

I RECEIVED AND ACCEPT
PLEASE CLICK HERE TO DOWNLOAD THE EMERGENCY PREPAREDNESS PLAN
I have seen and agree to the Emergency Preparedness Plan in the link above.*

I RECEIVED AND ACCEPT
Permissions

MEDIA/ARTWORK AUTHORIZATION:
From time to time our facility may photograph or video your child for portraits, crafts, posting a project in our classroom, newspaper or blog posts our website, and social media pages. I hereby do give consent for the facility to take photographs and or videos of my child.*

I GIVE CONSENT
Medical Emergency
Our facility may need to access your Childs health records for shot and immunization records.*

I AUTHORIZENO AUTHORIZATION
I hereby give permission to personnel of AKG to authorize any x-rays, tests, procedures, anesthetic, surgery or treatment on behalf of, and to provide or arrange for any transportation of, my child as may be required in the event of an emergency. If I, or the emergency contacts designated previously, cannot be contacted, I hereby give permission to a licensed physician, or other qualified health care provider as may be appropriate, to administer such treatment to my child, the participant, as may be necessary under the circumstances, including the hospitalization of my child.*

I ACCEPT
USE AND HOLD HARMLESS LIABILITY WAIVER
In consideration of the acceptance of my application for the above program, I hereby waive, release, and discharge any and all claims for damages for personal injury, property damages or which may hereafter occur to me as a result of participation in said event. This release is intended to discharge in advance A Kids Gym Learning Academy, its officials, officers, employees, volunteers and agents from liability, even though that liability may arise out of perceived negligence on the part of persons mentioned above. It is understood that some recreational activities involve an element of risk or danger of accidents, and knowing those risks, I hereby assume those risks. It is further understood AKG does not furnish personal medical coverage for any activities held within the facility and property and agreed that this waiver, release and assumption of risk is to be binding on my heirs and assignees. I understand I will be responsible for all financial obligations connected.*

I ACCEPT
Signature*

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Agreements
Parents as Partners

I acknowledge that I viewed the parent as partners form in the parent information station on the website www.akidsgym.com/parent-info I agree to abide by the policies set forth.
Signature*

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Emergency Closures

In the event of an emergency closure, utility outage, inclement weather closure, health department closure or government shutdown parents will be notified via phone, email or communication app. Should the center or your child's classroom need to close for any reason, tuition will not be refunded or reduced for closures of less than 14 school days.
Signature*

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Health and Illness

At A Kids Gym Learning Academy we understand that children will have stuffy noses and coughs at times. We do ask however, that if your child exhibits of the following symptoms that you please keep them home. Guardians agree to keep or take their child home within 45 min of being called to pick up. You agree to keep your child home until they symptom free for 24 hours. Here are the symptoms: Fever 100.4 or higher, Diarrhea (3 contained in diaper, 2 out of diaper/clothing), Vomiting, runny nose with green discharge, Rash that is suspicious, Discharge from eyes, Lice and nits, Communicable diseases (hand foot and mouth, chicken pox, covid-19, measles, mumps, influenza, RSV, norovirus etc.), Ring worm, impetigo, strep throat, whooping cough, croup, difficulty breathing. requiring one on one care, lethargic.
Signature*

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Shot & Immunization Records

Parent must provide and maintain current physical examination and immunization records, as required by the Health Department. I understand that failure to provide or update these forms can be cause for temporary disenrollment.
Signature*

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Parent Orientation

This is your orientation checklist. This orientation list is intended to help you understand what you need to know when you leave your child in our care. If an area below isn’t covered please let your director know. Tour of the facility - Check in/out procedures - Late pick up fees - Tuition - Needs of the Child - Non-Smoking policy - Procare invite - School Calendar - School Facebook page and Family Facebook group - Ice Cream Social
I HAVE READ THE AGREEMENT, FULLY UNDERSTAND IT, AND GRANT PERMISSION FOR MY CHILD TO PARTICIPATE IN THE PROGRAM IDENTIFIED ABOVE.
Signature of Parent or Legal Guardian:*

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Date

MonthDayYear
Date

Tuition Express - FOR NEW STUDENTS/UPDATES

We are excited to offer the safety, convenience and ease of Tuition Express- a payment processing system that allows on-time tuition and fee payments to be made from your bank or credit card. All credit and debit cards will have a 3% fee added. ACH transactions have no fee.
Electronic Funds Transfer Authorization

I hereby authorize A Kids Gym Learning Academy to initiate charges to the below reference credit card or bank account. To properly affect the cancellation or change of this agreement I am required to give 30 days written notice.
Name of Primary Payer on this account

First NameLast Name
What payment method do you choose?
Section B Bank Account No fee added

Please only fill out this section if you are using your bank account for payments
Name

First NameLast Name
Bank Name
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Type of Bank Account

CheckingSavings
Bank Routing Number
Bank Account Number
Signature

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I WOULD LIKE TO…

DROP GYM/NINJA/CHEER CLASSES - TWO WEEK NOTICEADD CAMP WEEKS/DAYSDROP PRESCHOOL - 30 DAY NOTICECHANGE GYM CLASS/DAY TIMECHANGE PRESCHOOL ATTENDANCE DAYS/TIMESDROP/CHANGE CAMP WEEKS
DESCRIBE ADD/DROP CHANGE INFORMATION HERE
TWO WEEK NOTICE TO DISENROLL APPLIES TO ALL CHANGES TO CAMP WEEKS AND GYM CLASSES. 30 DAYS TO PRESCHOOL AND AFTERSCHOOL.
Should be Empty:

	Tuesday	Wednesday	Thursday	Friday	7AM-6:30PM	8AM-5PM	N/A
12/26-29
1/2-1/5

	Monday	Tuesday	Wednesday	Thursday	Friday	7AM-6:30PM	8AM-5PM	N/A
WEEK 2 - 6/2-6/6
WEEK 3 - 6/9-13
WEEK 4 - 6/16-20
WEEK 5 - 6/23-27

	Monday	Tuesday	Wednesday	Thursday	Friday	7AM-6:30PM	8AM-5PM	N/A
WEEK 7 - 7/7-11
WEEK 8- 7/14-18
WEEK 9 - 7/21-25
WEEK 10 - 7/28-8/1
WEEK 11 - 8/4-8

Student Enrollment & Release Form

Child Information

Parent/Guardian Information

Parent/Guardian 2 Information

Authorized Child Pick Up and Emergency Contacts

Written Consent is Given For:

NON-INGESTIBLE OVER THE COUNTER (OTC) MEDICATION AUTHORIZATION FORM

FAMILY HANDBOOK

KNOW YOUR CHILDCARE

DISTRACTED ADULT HANDOUT

PLEASE CLICK HERE TO DOWNLOAD THE EMERGENCY PREPAREDNESS PLAN

Permissions

Agreements

Parents as Partners

Emergency Closures

Health and Illness

Shot & Immunization Records

Parent Orientation

Afterschool Tuition Agreement

Preschool Tuition Agreement

Choose which schedule you'd like for your child at AKGLA:

2025 Camp Kids Gym Enrollment Application

PLEASE CLICK HERE TO DOWNLOAD OUR CAMP KIDS GYM SUMMER HANDBOOK.

Guardians Information

Emergency Contacts

Medical Information

Medical Emergency

USE AND HOLD HARMLESS LIABILITY WAIVER

Discipline Practices at A Kids Gym

Health and Illness

Field Trips

Tuition Express - FOR NEW STUDENTS/UPDATES

Section B Bank Account No fee added