Step 1 of 4

General Information

Name(Required)

First Last

Birth Date(Required)

Age(Required)

School Attending(Required)

Grade Entering(Required)

5-days or 3-days?(Required)

5-day rate

3-day rate

(If only 3 days) Please select which days they will attend:

Monday

Tuesday

Wednesday

Thursday

Friday

Address(Required)

Street Address Address Line 2 City State ZIP Code

Parent/Guardian Information

Parent/Guardian 1 Name(Required)

First Last

Parent/Guardian 1 Cell Phone(Required)

Parent/Guardian 1 Work Phone

Parent/Guardian 1 Home Address(Required)

Street Address Address Line 2 City State ZIP Code

Parent/Guardian 1 Email Address(Required)

Parent/Guardian 1 Place of Employment

Parent/Guardian 1 Work Hours

Parent/Guardian 2 Name

First Last

Parent/Guardian 2 Cell Phone

Parent/Guardian 2 Work Phone

Parent/Guardian 2 Home Address

Street Address Address Line 2 City State ZIP Code

Parent/Guardian 2 Email Address

Parent/Guardian 2 Place of Employment

Parent/Guardian 2 Work Hours

Emergency Contact Information

Emergency Contact Name

First Last

Relationship to Child

Is This Person Authorized To Take The Child From FAC?

Yes

Emergency Contact Cell Phone

Emergency Contact Work Phone

Emergency Contact Address

Street Address Address Line 2 City State ZIP Code

List All Other Adults Who Are Authorized To Take Child From FAC:

Name

First Last

Phone

Relationship

Name

First Last

Phone

Relationship

Name

First Last

Phone

Relationship

Consent/Acknowledgment

I hereby give the Director of the Child Care Facility or his/her appointed representative permission to give my child Acetaminophen. I understand I will be notified if that medication has been administered

I hereby give written permission for the use of suntan lotions/suncscreen for my child in permitable weather. In accordance with Minimun Licensing Requirements: DCCECE/Child Care Licensing Unit: 1100.1101.17

This is a statement of verification that I have been informed that child care licensing/child maltreatment investigators and/or law enforcement may possibly interview my child for the purpose of determining licensing compliance or for investigative purposes. This is in accordance with Minimum Licensing Requirements: DCCEDE/Child Care Licensing Unit: 200.201.4

This is to acknowledge that I have read and will comply with the rules as stated in the Kid's Fit Fun FACtory Parent Handbook (Attached at top)(Required)

This is a statement of verification that I have been informed of the behavior guidance policy practiced. (Attached at top)(Required)

I, the parent/guardian of this child, understand that I may ask for a conference with the caregiver(s) as needed.

I verify that this form is complete in its entirety and that the parent handbook was given (attached at top)

I, the Parent/Guardian, have read, understand, and agree with the Fayetteville Athletic Club Kid's Fit Fun FACtory Discipline Policies(Required)

The discipline policy of the Fayetteville Athletic Club Kid's Fit Fun FACtory will be that anytime a child's behavior jeopardizes the safety of him/herself, others, or is acting in a disruptive manner the child will be removed from the class or program. The FACtory uses a timeout situation to encourage good behavior. A child who has to take a time out will be taken out of class participation and must sit alone quietly under staff supervision for 1 minute for each year of age. After the second offense , another time out will be given. Following a third offense the child is sent home for the remainder of the day. Also, the parents and the child will have to schedule a conference with the director to discuss the problem. Continuous or more serious behavioral problems may result in termination from the Kid's Fit Fun FACtory program.

I agree to abide by the Billing Policy that has been presented to me by the Fayetteville Athletic Club. I hereby acknowledge that all information provided by the undersigned is accurate and that I have read and understand the preceding prior to the signing and agree to all terms outlines above. I understand that the policy may change under the discretion of the billing office and/or director of the program.

Kids Fit Fun FACtory programs will not admit a participant without Payment Agreement & Registration forms completed by bill payer and registration fees are paid. Each program may have separate and different fees and policies. Program costs are not affected when children cancel or miss days for which they are registered. No substitutions can be made for missed days. Drop in days are not available and children can only attend camp on days which they are registered and paid for. Payment must be made before child can attend camp. Non-payment by due dates will result is forfeit of student’s space in the program. Memberships, private lessons, personal training, and special programs are not included in fees but discounts may apply. FAC member discounts are only applicable if the child holds a “Junior Membership”. Any other discounts must be arranged with Director in writing prior to start of camp. FAC member discounts are void and additional charges will occur if membership is canceled during the time of camp attendance. The non-member rate will be charged to your account retroactively. Changes or cancellations in any registration must be made in writing to the director. This does not guarantee refund or credit of payments that have been made or cancellation any outstanding balances. A $25 fee is charged to any returned payments. Any payments made after a returned payment must be in cash or money order form. Failure to comply with payment will result in suspension of the participant. Non-payment after 60 days of billing date may be subject to collection agencies. Fayetteville Athletic Club accepts cash, money order, checks, Visa, Master Card, Discover, American Express. FAC will not accept any temporary checks. Monthly auto draft and FAC club account charge is not available for weekly programs such as camp, preschool or afterschool. For your convenience, a weekly draft may be set up on credit/debit card only.

No child will be admitted into any FAC program if this form is not signed by a parent/legal guardian. By signing this form, you are releasing all claims for injury you or the participant might sustain through any of our programs. I agree to assume full risk and to waive, relinquish, and release all claims I and or the participant may have against, indemnify, hold harmless, and defend the Fayetteville Athletic Club. This release includes as well FAC officers, agents, servants, and employees from such claims resulting from injury, damages,or loss sustained on account of participation in this FAC program or event. I understand that I am responsible for all personal insurance and the participant's family must cover any medical costs incurred. I also understand that every precaution is taken to protect the safety of each participant. I agree to emergency treatment by a physician or hospital in the event that I or the emergency contact listed cannot be reached.(Required)

After School Registration Form

General Information

Parent/Guardian Information

Emergency Contact Information

List All Other Adults Who Are Authorized To Take Child From FAC:

Medical Information

Consent/Acknowledgment

Payment Information

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