EmailMe Form - 26/27 After School Program

AFTER SCHOOL PROGRAM LOCATION

What State do you live in? *

Connecticut

Florida

Georgia

North Carolina

Pennsylvania

Texas

Your FIRST Week that you will need After School Services? *

* Please double check with your Camp Start date as different Cities start at different times

If on a Selected Day - What Date?

I am Registering... *

PARENTS INFORMATION

Mother/ Guardians Full Name

Mother Guardians Cell Phone Number

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

Mother/ Guardians Email

Mothers Facebook Name

We will add you to our ALM FB Page for info and to Network

Mothers Instagram Handle

We will add you to our ALM IG Page for info and to Network

Father/ Guardians Full Name

Father /Guardians Cell Phone Number

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

Father/ Guardians Email

Fathers Facebook Name

We will add you to our ALM FB Page for info and to Network

Fathers Instagram Handle

We will add you to our ALM IG Page for info and to Network

Authorized Pickup
Please list the people that are authorized to pickup your child at the end of the day. (Please write name/phone number/relationship)

Are you or your Spouse a School Teacher?

Yes, I am a teacher

No, I am not a Teacher

If so, What School do you teach in?

possibly help us in marketing efforts

Do you or your Spouse own a own business?

Yes, I own a Business

No, I do not own a business

If so, What Business Industry are you in?

Local Business Netwoking Opportunity

FIRST CHILDS INFO

#1: Childs First Name *

#1: Childs Last Name *

#1: Childs Date of Birth *

#1: Childs School Name

#1: Childs Fav Sport/ Activity

#1: Childs Shirt Size

SECOND CHILDS INFO

#2: Childs First Name

#2: Childs Last Name

#2: Childs Date of Birth

#2: Childs School Name

#2: Childs Fav Sport/ Activity

#2: Childs Shirt Size

THIRD CHILDS INFO

#3: Childs First Name

#3: Childs Last Name

#3: Childs Date of Birth

#3: Childs School Name

#3: Childs Fav Sport/ Activity

#3: Childs Shirt Size

FOURTH CHILDS INFO

#4: Childs First Name

#4: Childs Last Name

#4: Childs Date of Birth

#4: Childs School Name

#4: Childs Fav Sport/ Activity

#4: Childs Shirt Size

INSURANCE

Do you need ALM Sports Insurance?
ALM Insurance cost $10 per week * *

Will cover one week, per family of 3
*You will Not pay this fee now;
this will be paid once you pay for your Camp Week

Primary Insurance Details
(your childs insurance carrier and policy number)

MEDICAL / ALLERGIES

Medical

If your child does not have any, please leave blank

Allergies

If your child does not have any, please leave blank

REFERRALS

How Did you hear about ALM Sports After School Program *

What was the name of the Person / Organization that recommended you about the Camp (if applicable)

if you remember the name of the person - Please put their Full name here

DISCLAIMER

Notice of Exemption *
I agree and understand that this child care facility is exempted by the Department of Children and Families from state licensure requirements. *

Yes, I agree.

I, the parent/guardian of the child (children) registered in this application, acknowledge that I have been informed that this program is not a licensed child care facility. I also understand this program is not required to be licensed by the Department of Children and Families
and this program is exempt from state licensure requirements.

TERMS & CONDITIONS

I have read and agree to the Terms of Service *

Yes, I agree.

If your child is covered by a private insurance, you must provide us with proof of your child’s insurance coverage. If your child is not; We offer this through ALM Insurers at a cost of $10.00 for up to 5 days during the After School Program. I give consent for my child to take part in the activity and consent to emergency treatment as necessary. I accept that the organizers and their employees are not under any liability whatsoever in respect of injury, loss or damage whilst on the course, other than imposed by law. I also allow ALM Sports to take photos for advertising and promoting purposes only; if I do not want my child's photo to be taken I will email admin@almsports.com to let them know. I confirm that my personal insurance is correct and bears responsibility in case of accidents. I confirm that I am legally entitled to give this consent and understand all payments received are non-refundable.

Only the Registration Fee will be Charged. *

Yes, I understand.

I confirm that I am legally entitled to give this consent and understand this registration fee is non-refundable unless it is a fault of ALM Sports and/or if the Program does not open.

What Payment Options would you want to pay for the Camp weeks? *

We will contact you to go over the different payment options.

Signature

Clear

1 Child

2 Children

3 Children