Relation to Child
Email
Primary Phone
Secondary Phone
Home Address
City
State
Zip
Employer Name
Employer Address
Work Phone
Work Email
If Yes, What Position?
School Name
Secondary Parent/Guardian Information
Secondary Parent First Name
Last Name
Relation to Child
Email
Primary Phone
Secondary Phone
Home Address
City
State
Zip
Employer Name
Employer Address
Work Email
Work Phone
If Yes, What Position?
School Name
Billing Settings
First Name
Last Name
Relationship to Child
Primary Phone
Secondary Phone
First Name
Last Name
Relationship to Child
Primary Phone
Secondary Phone
First Name
Last Name
Relationship to Child
Primary Phone
Secondary Phone
Pickup Questions
Question 1
Answer 1
Question 2
Answer 2
First Name
Last Name
Relationship to Child
Phone
First Name
Last Name
Relationship to Child
Phone
Child Information
Child's First Name
*
Last
*
Date of Birth
Nickname
*
Address
City
State
Zip
Phone
Grade
Select Grade
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
Start Date
Names of Siblings Attending TAC
Allergy Information
Describe Effects and Reactions
Special Instructions Including Inhaler / Epi-Pen usage
Physician's Name
Phone
Dentist Name
Phone
Name of Preferred Hospital/Clinic for Emergency Care
In consideration of the services to be provided by The Adventure Club, Inc., and for other good and valuable consideration, the undersigned, for myself and for my minor child, and any and all family members, heirs, representatives, executors, administrators, and assigns of myself or of my minor child, hereby accepts full responsibility and assumes all risk, for my minor child’s use of any and all apparatuses, appliances, facilities, privileges or services, of any nature, which is/are owned, operated or provided by The Adventure Club, Inc. While engaging in any contact, game, function, exercise, competition or any other activity operating, organized, arranged, or sponsored by The Adventure Club, Inc. either on or off their premises, my minor child shall do so at his or her own risk.
I hereby release and hold forever harmless The Adventure Club, Inc., its owners, employees, representatives, and agents (collectively, “the releases”), and each of them, from any and all losses, claims, injuries, damages, or liability of any kind, sustained or incurred by us resulting therefrom, whether caused by the negligence of the releases or otherwise. I specifically agree to indemnify and hold harmless The Adventure Club, Inc., its owners, employees, representatives, and agents as to any loss, cost, claim, injury, damage or liability, sustained or incurred by using the facilities, equipment, or services, of The Adventure Club, Inc., which is caused by an act or omission, whether negligent or otherwise, of an employee, representative, or agent of The Adventure Club, Inc.
I understand/acknowledge that it is my responsibility to ensure that my minor child participates only in those activities for which he/she has the required physical conditioning. My signature below indicates that I have carefully read and freely signed this waiver, and constitutes my full acceptance of this waiver.
I understand that in an effort to prevent any potential conflict of interest, childcare outside TAC hours by TAC staff members is discouraged. However, should I hire TAC staff, it must be outside the TAC premises and with the understanding that such arrangements and payments for services are solely between me and the member. TAC does not sanction the arrangements, and I agree to hold TAC harmless from any such arrangement. If a center staff member chooses to baby-sit for an enrolled child, the Site staff member and I must request and sign a Liability Release Form to be kept in the child’s file.
I give my full permission and consent to TAC to use and keep my child(ren)'s artwork; photographs or moving pictures they may take or produce at the Club’ or photographs or moving pictures in which my child(ren) may appear.
Thank you for enrolling your child at The Adventure Club. It is our mission to provide a before and after school program that is an E nriching, I nspiring, E ducating and E xciting place for your child to learn and grow while meeting the childcare needs of our parents, the school and communities we serve.
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