Registration Form

Playgroup and After School Programs

 
 
Child's Information
Child's Name *
Child's Name
Date of Birth *
Date of Birth
Parent/Guardian Information
Parent/Guardian 1 *
Parent/Guardian 1
Home Number *
Home Number
Cell Number *
Cell Number
Address *
Address
Parent/Guardian 2
Parent/Guardian 2
Home Number
Home Number
Cell Number
Cell Number
Address
Address
Summer Camp Attendance
Please check requested days *
Please check off requested options: *
Emergency Contacts
Emergency Contact 1 *
Emergency Contact 1
Phone Number *
Phone Number
Emergency Contact 2 *
Emergency Contact 2
Phone Number *
Phone Number
Health Information
Pediatrician Name *
Pediatrician Name
Pediatrician Office Number *
Pediatrician Office Number
Pediatrician Address *
Pediatrician Address
Background Information
Is a second language spoken at home? *
Parental Agreement
Please initial the following items below if you are in agreement with our terms.
1. PHOTOGRAPHS *
During the course of the session, we will be taking photographs and videos of your Child. This will not be shared with anyone outside of the PPL unless we have been authorized by you:
2. OUTINGS *
At the Director’s discretion, PPL classes may be conducted outside or involve a neighborhood walk
Payment for the session should be remitted prior to the first day of class.
Make-ups for missed sessions cannot be guaranteed or reimbursed.
I understand appropriate supervision of my Child will be provided while they are in attendance at PPL. I release Parachute Play & Learning and individuals from liability in case of accidents during activities related to the class, as long as normal safety procedures have been taken.
Confirmation
BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.