The Kids Place Application
(Please
print and complete. Payment
required with application)
Child's Name__________________________________
Age_____
Date of Birth_________________
Parent/Guardian's Name___________________________
Address_______________________________________
______________________________________________
City
State
Zip
Email Address__________________________________
Home Phone____________ Cell Phone _____________
Allergies_______________________________________
Emergency Contact______________________________
|
Release: In case of emergency and I cannot be reached, I authorize the staff of The Kid's Place to obtain whatever medical treatment deemed necessary for the welfare of my child. I further understand that I will
be financially responsible for all charges and fees incurred in the rendering of said emergency treatment, regardless of whether or not my medical insurance would cover these fees, hereby giving my consent to my child's participation in all the activities of The Kids Place, and hereby absolve, release and hold harmless The Kids Place and all of it's attorneys, employees, owners, successors assigns and other affiliates from any and all liability for any injuries or damages that my child may suffer in connection with the activities sponsored by The Kids Place or in which my child may participate. |
Signature:
____________________________________ Date:
__________________