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: __________________