GymKix Enrichment Academy

GymKix Enrichment Academy

Registration for Playful Pathways, After School Program, and Camps
Parent/Guardian Name*

First NameLast Name
Email*
example@example.com
Cell Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
YesNoNot ApplicableOther
YesNo
Parent/Guardian Name (Secondary)

First NameLast Name
Email
example@example.com
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Address (if different than Primary Parent/Guardian)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

EMERGENCY & AUTHORIZED ADULTS (NOT A PARENT/GUARDIAN)

Please provide at least ONE Emergency Contact and ONE authorized Pick-up, other than Mom and Dad. Please indicate if the person listed is an Emergency Contact, authorize Pick-up or both. Emergency Contact: a person to contact in case of an emergency if parents / guardian cannot be reached. Authorized Pick-up: an authorized person to pick up, besides the parent / guardian. Children will only be released after verification of ID.
First Adult's Name*

First NameLast Name
Relationship*
Cell Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency ContactAuthorized to Pick Up
Second Adult's Name*

First NameLast Name
Relationship*
Cell Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency ContactAuthorized to Pick Up

AUTHORIZATION FOR EMERGENCY MEDICAL ATTENTION

In the event I cannot be reached to make arrangements for emergency medical care, I give consent for the facility to secure any and all necessary emergency medical care for my child(ren).
Metroplex: 2201 S. Clear Creek, Killeen / Phone: 254-526-7523Darnall Army Medical Center: 36065 Santa Fe Ave, Fort Hood / Phone: 254-288-8000Other
Signature

SPECIAL CARE INFORMATION

List any special care information that your child may have, such as allergies, any prescribed medication, and any other information which caregivers should be aware of (to include but not limited to: hospitalization in the last 12 months, injuries, previous serious illnesses, medications, and allergies). For Food Allergies, a Food Allergy Emergency Plan will need to be completed and signed by you and a healthcare professional. For prescribed medication, a Medical Authorization form will need to be completed.
Child's Name

First NameLast Name
Special Care Information
Child's Name

First NameLast Name
Special Care Information
Trophy's Health Bar Agreement

We offer a variety of healthy snack options for our students. These purchases can be added to your weekly charges for your convenience.
YesNo
YesNo
Daily Charge Limit:
Item Exclusions (example: no shakes, no candy, etc..):
Other Limits/Exclusions:

Statement of Understanding & Assumption of Risk

In consideration of allowing the previously-declared participant(s) to begin participation in GymKix activities, while on the premises and property of said Center, theundersigned, for themselves, and/or being the legal and acting guardian of participant, acting for themselves and on behalf of the participant, release and hold harmless GymKix, L.L.C., its owners, employees, and agents of and from any and all liability, claims, demands, and causes of action whatsoever, arising out of or related to any loss, damage, or injury, including death, that may be sustained by the participant and/or the undersigned, while in or upon the premises upon which GymKix is conducted, or any premises under the control and supervision of GymKix, L.L.C., its owners, employees, or agents or in route to or from any of said premises, or while at any premises or place when activities sponsored by or participated in by GymKix, L.L.C., its owners, agents, or employees. GymKix is not responsible for children contracting illnesses to include COVID19 or any variant.. Assumption of Risk - Participation in physical activities can involve motion, rotation, and height in a unique environment and as such carries with it a certain assumption of risk. The undersigned and the participant(s) choose to voluntarily enter upon said premises under the control of said corporation, knowing their present condition and knowing that said condition may become more hazardous and dangerous during the time the participant or the undersigned is upon said premises. The undersigned and the participant(s) voluntarily assume any and all risks of loss, damage, or injury that may be sustained by the participant(s) and/or the undersigned or any property owner by them while on or upon said premises described above. The corporation may but shall not be obliged to carry insurance on the participant(s), and the existence of insurance shall not change, alter, or increase theliability of the corporation to the participant and the undersigned or affect the terms of this Release. In signing this Release, the undersigned acknowledges:a) That he/she has read thoroughly and understands completely, the terms of Registration and Release and signs it voluntarily.b) That the undersigned signing either for themselves, or as Legal Guardian is, in fact, the true and legal guardian and has the consent of theparticipant.
Statement of Understanding & Assumption of Risk Signature*

Medical Release

The undersigned gives permission for the GymKix, L.L.C. owners, officers, employees, and/or agents to seek emergency medical treatment for the participant(s) in the event they are unable to reach any parent or guardian. The undersigned also agrees that they themselves will be responsible for any financial debt incurred by said action.
Medical Release Signature*
Transportation & Field Trip Release

I give permission for my child to be transported either by GymKix transportation or by other commercial or public transportation for field trips or school pick up and drop-off at GymKix.
Transportation & Field Trip Release Signature*
Marketing Release

I understand that my child’s likeness may be used in GymKix ads, promotional videos, website material, or various other marketing. These images will be used forGymKix purposes only, and will not be given or sold to outside companies or individuals.
Marketing Release Signature*

WAIVER & RELEASE FOR COMMUNICABLE DISEASES INCLUDING COVID-19 ASSUMPTION OF RISK / WAIVER OF LIABILITY / INDEMNIFICATION AGREEMENT

In consideration of being allowed to participate on behalf of GymKix and related events and activities, the undersigned acknowledges, appreciates, and agrees that:1. Participation includes possible exposure to and illness from infectious diseases including but not limited to MRSA, influenza, and COVID-19. While particular rules and personal discipline may reduce this risk, the risk of serious illness and death does exist; and,2. I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASES or others, and assume full responsibility for my participation; and,3. I willingly agree to comply with the stated and customary terms and conditions for participation as regards protection against infectious diseases. If, however, I observe and any unusual or significant hazard during my presence or participation, I will remove myself from participation and bring such to the attention of the nearest staff member immediately; and,4. I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, HEREBY RELEASE AND HOLD HARMLESS GymKix, their officials, agents, and/or employees, other participants, sponsoring agencies, sponsors, advertisers, and if applicable, owners and lessors of premises used to conduct the event (“RELEASEES”), WITH RESPECT TO ANY AND ALL ILLNESS, DISABILITY, DEATH, or loss or damage to person or property, WHETHER ARISING FROM THE NEGLIGENCE OF RELEASEES OR OTHERWISE, to the fullest extent permitted by law.
I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IF FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.*

GymKix Enrichment Policy Reminders

Please read and initial all statements regardless of your current enrollment so that you are familiar with these important reminders should your child change/add programs.
ALL PROGRAMS: PLEASE INITIAL THAT YOU UNDERSTAND THE FOLLOWING:
- There is a $10 late fee for every 15 minutes that you are late for scheduled pick up.
- Initials: Type a label*
- If your child does not have the required attire for their scheduled GymKix class or free play, they will not be able to participate for that day.
- Initials: Type a label*
- If your child is removed for behavior/safety violations or illness, you will be charged the daily rate for days attended and the remaining amount will be credited to your account (if applicable).
- Initials: Type a label*
- I understand all items need to be labeled with my child's name
- Initials: Type a label
AFTER SCHOOL: PLEASE INITIAL THAT YOU UNDERSTAND THE FOLLOWING:
- If your child’s schedule changes and you DO NOT need GymKix to pick them up (due to illness, absence, tutoring, etc.) you MUST notify GymKix by 1:00 p.m. If you fail to notify GymKix by 2:00 p.m. your account will be billed $7.50.
- Initials: Type a label*
- Payments will be automatically drafted every Friday.
- Initials: Type a label*
- In order to hold a spot ($25 per week), notice must be given no later than the week PRIOR to the time off.
- Initials: Type a label*
SUMMER/DAY CAMPS: PLEASE INITIAL THAT YOU UNDERSTAND THE FOLLOWING:
- I understand I must bring (no food delivery): a lunch, water bottle, and at least two snacks each day. If I do not provide lunch for my child, then one will be provided and my card on file will be charged $10.
- Initials:
- I understand I must bring spray/touchless sunscreen for my child if I want it applied
- Initials:
- I understand I must have a change of clothes packed each day
- Initials: *
- I understand I must have a change of clothes packed each day
- Initials:
- I understand that the $25 deposit is NON-REFUNDABLE (no exceptions).
- Initials:

Texas Health and Human Services Commission Form 1099 – Operational Discipline and Guidance Policy

Discipline and guidance must be individualized and consistent for each child. It must be appropriate to the child’s level of understanding and directed toward teaching acceptable behavior and self-control. Acceptable Discipline and Guidance Practices: Encouragement of positive behavior - Clear and positive expectations - Redirection - Brief supervised separation (time-out), limited to 1 minute per year of age. Prohibited Discipline Practices: Corporal punishment or threats - Punishment related to food, naps, or toilet training - Humiliation, yelling, or harsh language - Isolation in locked or dark areas - Physical restraint not allowed by standards
Signature

FINAL ADMISSION CONFIRMATION

I confirm that all of the information provided in this Admission Form is complete and accurate to the best of my knowledge. I agree to update GymKix if any pertinent information changes. I have read and will comply with the GymKix Enrichment Academy Parent Handbook (updated and emailed every year - it is my responsibility to make sure I have read and understood the most up-to-date policies) and understand that I will be held fully responsible for its terms and conditions. I agree to the late charges and administrative fees that are established for the GymKix Enrichment Academy. I understand that these fees will be charged automatically.
Signature*
Should be Empty:

GymKix Enrichment Academy

Child's Information

Water Activities

Partnering to Support Your Child’s Growth and Comfort

2nd Child's Information

Water Activities

Partnering to Support Your Child’s Growth and Comfort

3rd Child's Information

Water Activities

Partnering to Support Your Child’s Growth and Comfort

EMERGENCY & AUTHORIZED ADULTS (NOT A PARENT/GUARDIAN)

AUTHORIZATION FOR EMERGENCY MEDICAL ATTENTION

SPECIAL CARE INFORMATION

Trophy's Health Bar Agreement

Statement of Understanding & Assumption of Risk

Medical Release

Transportation & Field Trip Release

Marketing Release

WAIVER & RELEASE FOR COMMUNICABLE DISEASES INCLUDING COVID-19 ASSUMPTION OF RISK / WAIVER OF LIABILITY / INDEMNIFICATION AGREEMENT

MEDICATION CONSENT

GymKix Enrichment Policy Reminders

Texas Health and Human Services Commission Form 1099 – Operational Discipline and Guidance Policy

FINAL ADMISSION CONFIRMATION