ENROLLMENT FORM

YOUTH LIFE CENTER REGISTRATION FORM
SPECIAL NOTE: Before you get started, you will need your child's
- Medical Provider and Insurance Information
- Registration payment is required to submit your application
CHILD'S INFORMATION
Child's Photo *
Child's Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Age *
Gender *

Male Female
What school does your child attend? *
Is your child in Kindergarten?
Grade *
SELECT YOUR CHILD'S PROGRAM(S)
I'm enrolling my child in the following program(s) *

PRIMETIME ALL ACCESS PROGRAM FANTASTIC SCHOLASTICS TUTORING PROGRAM MUSICAL THEATER PROGRAM WINTER BREAK SPRING BREAK FALL BREAK SCHOOL CLOSURE CARE
PARENT CONTACT INFORMATION
Primary Parental Contact *

Mother Father Grandparent Foster Parent
Parent's Name *

First Name Last Name
Cell Phone Number *

Area Code Phone Number
Email *
example@example.com
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
EMPLOYER INFORMATION
Employer's Company Name *
Work Phone Number *

Area Code Phone Number
EMERGENCY CONTACT & AUTHORIZED PICK-UP
List up to 3 other people (other than parent/guardian) who are authorized to pick up your child and should be contacted in case of a medical emergency or emergency pick-up if parent/guardian cannot be reached. Anyone picking up a child must provide a photo I.D. and be listed below
Emergency Contact *

First Name Last Name
Phone Number *

Area Code Phone Number
Relationship to child? *
Authorized Pick-up #1

First Name Last Name
Phone Number

Area Code Phone Number
Authorized Pick-up #2

First Name Last Name
Phone Number

Area Code Phone Number
Authorized Pick-up #3

First Name Last Name
Phone Number

Area Code Phone Number
MEDICAL INFORMATION
Does your child have food allergies? *

Yes No
If YES explain or enter N/A: *
Does your child have seasonal allergies? *

Yes No
If YES explain or enter N/A: *
Does your child have special needs or disabilities? I *

Yes No
If YES explain or enter N/A: *
Has your child been professionally diagnosed with any of the following: *

ADD ADHD AUTISM BIPOLAR DISORDER ODD IEP None of the above
If YES explain or enter N/A: *
Does your child take prescription medication? *

Yes No
If YES explain or enter N/A: *
By checking boxes below, these non-prescription medications may be administered without further authorization. Check all that applies. The Youth Life Center has my consent to administer basic first aid and the following non-prescription medications to my child such as: *

Tylenol Ibubprofen Benadryl Antacids Aloe Vera Sun Screen Visine Eye Drops I DO NOT CONSENT to any non-prescription medications to be administered to my child.
Primary Care Physician & Health Insurance Information
Doctor's Name *
Phone Number *

Area Code Phone Number
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Health Insurance Carrier *
Policy Number *
Phone Number *

Area Code Phone Number
POLICIES & WAIVERS
By checking each box, you are agreeing to Club Xhell Youth Life Center's

Policies and Waivers
Exempt Organization

Club Xhell Youth Life Center is not a state licensed Center. As a youth development organization, our Center is governed and abides by all of Bright From The Start's rules, regulations and recommended best practices. The Youth Life Center solely operates under the Bright From The Start Georgia Department exemption categories 290-2-2.05(f)8, EXMT: 16811, EXMT: 16810 and 290-2-2.05(f)7 for the purpose of providing enrichment, educational and recreational classes for school aged children during the academic school year, summer and intermittent school breaks.
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I have read and I agree - Exempt Organization
Behavior Policy

Club Xhell Youth Life Center is not a therapeutic environment; therefore, all parties understand the following: Should your child display violent, uncontrolled aggression and/or becomes combative and/or fragrantly disrespectful towards staff or any adult supervision, your child will be expelled without refund. Failure to disclose ANY behavior, mental, medical and/or physical disabilities or disorders or the severity of such is grounds for immediate expulsion. Should your child have an episode parents are legally liable and financially culpable for any damages to property or injury to staff, other children or persons harmed as a result of your child's behavior. Any such episode requiring the review of surveillance video/footage will be at the sole expense of the parent at a rate of $75 per hour or any portion thereof. Club Xhell Youth Life Center and its staff are released of liability for any actions taken to protect your child from being a threat to self, property or others; or in efforts to prevent the destruction of property. Such actions may include but is not limited to physical restraint, confinement and/or isolation in a specified space until released to a parent, law enforcement or authorized adult. If your child is expelled, there will be no verbal communication regarding the incident. Parents will be mailed an incident report within three (3) business days. Any false reports of abuse, neglect, inappropriate restraint or slander of any kind will result in immediate expulsion without refund and will result in legal actions.
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I have read and I agree - Behavior Policy
Accident Release of Liability

I certify that my child is physically fit, have sufficiently prepared or trained for participation in the activity or event, and have not been advised to not participate by a qualified medical professional. I certify that there are no health-related reasons or problems which preclude his/her participation in club activities or event.I HEREBY ASSUME ALL OF THE RISKS OF MY CHILD'S PARTICIPATING AND/OR VOLUNTEERING IN CLUB PROGRAMS, FIELD TRIPS, ACTIVITIES AND/OR EVENTS, including by way of example and not limitation, any risks that may arise from negligence or carelessness on the part of the persons or entities being released, from dangerous or defective equipment or property owned, maintained, or controlled by them, or because of their possible liability without fault.I acknowledge that this Accident Waiver and Release of Liability Form will be used by the Club Xhell Youth Life Center, sponsors,and organizers of the activity or event in which I may participate, and that it will govern my actions and responsibilities at said activity or event.In consideration of my participation in enrichment and recreational activities, I hereby take action for my child, myself, my executors, administrators, heirs, next of kin, successors, and assigns as follows:(A) I WAIVE, RELEASE, AND DISCHARGE from any and all liability, including but not limited to, liability arising from the negligence or fault of the entities or persons released, for my death, disability, personal injury, property damage, property theft, or actions of any kind which may hereafter occur to me including my traveling to and from this center, THE FOLLOWING ENTITIES OR PERSONS: Club Xhell Incorporated, DBA Club Xhell Youth Life Center and/or their directors, officers, employees, volunteers, representatives, and agents, the activity or event holders, activity or event sponsors, activity or event volunteers;(B) I INDEMNIFY, HOLD HARMLESS, AND PROMISE NOT TO SUE the entities or persons mentioned in this paragraph from any and all liabilities or claims made as a result of participation in this activity or event, whether caused by the negligence of release or otherwise.I acknowledge that Club Xhell Incorporated, DBA Club Xhell Youth Life Center and their directors, officers, volunteers, representatives, and agents are NOT responsible for the errors, omissions, acts, or failures to act of any party or entity conducting a specific event or activity on behalf of Club Xhell Incorporated, DBA Club Xhell Youth Life Center.I acknowledge that this activity or event may involve a test of a person's physical and mental limits and may carry with it the potential for serious injury, and/or property loss. The risks may include, but are not limited to, those caused by terrain, facilities, weather, condition of participants, equipment, vehicular traffic, actions of other people including, but not limited to, participants, volunteers, spectators, coaches, event officials, and event monitors, and/or producers of the event, and lack of hydration. These risks are not only inherent to participants, but are also present for volunteers.I hereby consent to receive medical treatment which may be deemed advisable in the event of injury, accident, and/or illness while enrolled in any Club Xhell Youth Life Center program, activity or event. I understand that treatment may include emergency transportation, x-rays or surgery in some circumstances for my child, and I agree to assume responsibility for charges associated with this or any other treatment given to my child.I understand that I may be photographed. I agree to allow my photo, video, or film likeness to be used for any legitimate purpose by the event holders, producers, sponsors, organizers, and assigns.This accident waiver and release of liability shall be construed broadly to provide a release and waiver to the maximum extent permissible under applicable law.The undersigned is a consenting adult or parent/authorized guardian who hereby represent that he/she is, in fact, acting in such capacity, has consented to his/her child or ward's participation in the activity or event, and has agreed individually and on behalf of the child or ward, to the terms of the accident waiver and release of liability set forth above. The undersigned parent or guardian further agrees to save and hold harmless and indemnify each and all of the parties referred to above from all liability, loss, cost, claim, or damage whatsoever which may be imposed upon said parties because of any defect in or lack of such capacity to so act and release said parties on behalf of the minor and the parents or legal guardian. I CERTIFY THAT I HAVE READ THIS DOCUMENT, AND I FULLY UNDERSTAND ITS CONTENT. I AM AWARE THAT THIS IS A HOLD HARMLESS RELEASE OF LIABILITY. I SIGN IT ON BEHALF OF MY CHILD AND OF MY OWN FREE WILL.
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I have read and I agree - Release of Liability
Payment Policy

REGISTRATION AND TUITION PAYMENTS are due in advance of service. Choose your preferred MONTHLY or BI-WEEKLY payment option. MONTHLY PAYMENTS are due on the last Friday of each month. $25 Late fee will be assessed if payment does not post by the last day of the month. BI-WEEKLY PAYMENTS are due on the 2nd and 4th Friday of each month. $25 Late fee will be assessed if payment does not post by following Monday. WEEKLY (option available during summer only) payments are due every Friday. AVAILABLE PAYMENT METHODS - CashApp, **PayPal or Money Order. **Paypal users will be assessed a 2.9% convenience fee We DO NOT ACCEPT CASH for tuition payments.
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I have read and I agree - Payment Policy
WE DO NOT ACCEPT CASH as a form of PAYMENT for registration or tuition.
Select your preferred payment schedule: *

Monthly on the 4th Friday of each month Bi-Weekly on the 2nd and 4th Friday of each month Intermittent Break (Spring, Winter, Fall)
Select your preferred payment method: *

CashApp direct to $youthlifecenter PayPal (Users will be charged a 2.9% convenience fee per transaction) Money Order payable to "Youth Life Center"
Medical Treatment

In the event of an emergency, Club Xhell Youth Life Center has my consent to seek medical treatment for my child. I understand that treatment may include emergency transportation, x-rays or surgery in some circumstances for my child, and I agree to assume responsibility for charges associated with this or any other treatment given to my child.
*

I have read and I agree - Medical Treatment
Cell Phone Policy

In efforts to manage the appropriate interactions between children, and infuse the art of engagement through interpersonal communication, usage of CELL PHONES ARE NOT ALLOWED. Children are permitted to use the office phone in the event of an emergent situation. Parents are asked to call the office if there is an emergent situation that requires you to speak with your child. If a child presents a cell phone, it will be confiscated and held in the office until it is retrieved by a parent. If your child repeatedly violates this policy they will be excused from the program.
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I have read and I agree - Cell Phone Policy
Field Trip Policy

I understand that field trips are a component of the school year and summer camp experience. I understand that most trips will be local which will allow for children to return between regularly scheduled hours. DURING SUMMER, I understand that group field trip excursions are an “WHOLE GROUP CAMP EXPERIENCE. I understand that if I elect for my child to NOT PARTICIPATE in the group field trip or my child misses the bus, my child will have to stay home because there will be no staff on site during the scheduled field trip times. Field trips are subject to change. I understand that at the Youth Life Center's discretion, that they reserve the right to disallow any child with disciplinary challenges from attending any field trip. I understand that all field trips are paid in advance and are nonrefundable.
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I have read and I agree - Field Trip Policy
Transportation Permission/Policy

My child has permission to be transported by Youth Life Center staff to field trips, outings and excursions. Modes of transportation my include 15-passenger vans, school buses of different sizes. My child may travel from the Center to the activity and make incidental stops along the way, as the youth adviser may deem necessary. I understand and acknowledge that participation in the activities involves inherent risks of injury to my child including risks associated with transportation by motor vehicle. I release Club Xhell Youth Life Center and their affiliates from liability for injury or damages which may result from my child's participation in this field trip. I have read, understand and discussed with my child that: 1. He/she will be traveling in a motor vehicle driven by an adult and that he/she must wear a seat belt at all times. 2. He/she is to respect peers and adults, the driver and vehicle at all times and is to refrain from any activity that would be categorized as disrespectful or distracting. All trash must be bagged and removed by the youth prior to leaving the vehicle. Loud music will not be allowed. 3. He/she will be expected to remain in the seat at all times and to follow the instructions provided by the driver and staff. 4. Please review with your child that riding in a motor vehicle may result in personal injuries or death from accidents, collisions, or acts by riders, other drivers or objects. His/her personal behavior can often increase or decrease the likelihood of these occurrences. I understand that my child is not required to participate in this activity, but I grant permission for him/her to do so, despite the possible risks. I recognize that by participating in this activity, as with any activity involving motor vehicle transportation, my child may risk personal injury or permanent loss. I hereby attest and verify that I have been advised of the potential risks, that I have full knowledge of the risks involved in this activity and that I assume any expenses that may be incurred in the event of an accident, illness or other incapacity, regardless of whether I have authorized such expenses.
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I have read and I agree - Transportation Permission/Policy
Photo/Media Permission

I give permission for Club Xhell Youth Life Center to publish in print, electronic, or video format, the likeness or image of my child and any photograph my child is in for promotional material. I understand that during the course of my child's enrollment at Youth Life Center he/she may be photographed, filmed or video typed. I release all claims against Club Xhell Youth Life Center with respect to copyright ownership and publication including any claim for compensation related to use of the aforementioned materials. I irrevocably consent to and authorize the unrestricted use by Club Xhell Incorporated dba Club Xhell Youth Life Center (CXYLC), CampXpressions, affiliates and advertising agencies ("Companies") of my child's name, photographs, works of art and identity in various Club Xhell Incorporated website and collateral material, as well as miscellaneous print publications and other media outlets, and any personal information that I supply to the Companies, in connection with advertising and promotion of the Companies and/or their products in any media, form or material selected by the Companies, without any right of prior review or further approval, whether such advertising and promotion is to the public, to the trade, or both, and in the corporate releases, newsletters and other communications of the Companies; and I hereby waive, and release and discharge said Companies and all agents, employees and officers of the Companies, including their agencies, media producers and customers from, any claims, liabilities and demands, past, present or future, including any that I do not now know of or anticipate arising in the future, none of which would affect my execution of this release if known to me, and waive all rights with respect to such use of my name, photograph, identity, and personal information.
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I have read and I agree - Photo/Media Permission
Electronic Signature

By entering my name below, I accept the above policies, waivers and releases. I am a parent or legal guardian of the registered who is currently under the age of 18. I grant permission for the registered to participate in Club Xhell Youth Life Center educational and enrichment programs.
Signature *

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Payment required to complete registration. *
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REGISTRATION FEE $ 25.00

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