EmailMe Form - DAY CARE REGISTRATION FOR OUSD STRIKE

Child *

First Last

Age *

Grade *

School *

Primary Emergency Contact
(Parent/Guardian) *

First Last

Phone 1 *

### - ### - ####

Phone 2

### - ### - ####

Email

Secondary Emergency Contact
(Parent/Guardian)

First Last

Phone 1

### - ### - ####

Phone 2

### - ### - ####

Names of persons authorized to take child from the facility:

Name/s

Relationship

*Child will not be allowed to leave without authorization from parent

I understand that if I am late to pick up my child, my credit card on file will be charged $1/min. *

Yes

HEALTH INFORMATION

Permission Given to
Seek Medical Attention

Yes

As the parent or authorized representative, I hereby give consent to Kids N Dance N Theater Arts to obtain Medical or Dental care prescribed by a duly licensed physician (MD) or dentist (DDS). This care may be given under whatever conditions are necessary to preserve the life, limb, or well being of the child named above.

List any pertinent health concerns:
- allergies
- medication
- diabetes, asthma, etc.
- NOTIFY OF EPI PEN NEEDS

All medications must be provided to the staff and administering directions must be detailed here. PLEASE CONFIRM NOTIFICATION AT SIGN IN

SOME LOGISTICS

Permission to transport *

Yes

THIS WILL ONLY OCCUR IF THE KIDS SEEM TO NEED IT: I give permission for my child to be transported to and from Roberts Park from Kids N Dance N Theater Arts

Booster Seat Needed *

Yes

No

For transportation in the van

Release of Liability *

Yes

Checking "Yes" indicates you agree to the following: I voluntarily enroll my child with full knowledge that there is risk of personal injury in any activity affiliated with KND. I agree neither I, my heirs, assigns or legal representatives will sue or make any other claims against Kids N Dance/Onstage, its members or employees for any degree of personal injury, property damage/loss, regardless of cause.

Is there anything else we might need to know about your child?

We want your child to have the best possible experience at camp. Is there anything we should know about your child that will help us know what their needs are?

Signature of parent/guardian who completed this form. You will next be directed to make your payment.

Clear

Use your mouse or touch pad to sign electronically

I UNDERSTAND THAT IF I AM NOT REDIRECTED TO REGISTRATION/PAYMENT
SITE I SHOULD CONTACT THE OFFICE TO CONFIRM MY ENROLLMENT *

Yes