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KIDSAMERICA? STUDENT REGISTRATION FORM P.O. Box 1034 - Perry GA 31069 - 478-987-2838kidsamerica@ I hereby warrant that I am entitled to legal custody and possession of my child(ren) and accordingly am authorized to place my child(ren) in the care of KidsAmerica and am further authorized to sign this agreement. I acknowledged by my signature on page 2 that the information, which I am giving, is current and that I have read, understand, and agree with all Policies and Procedures as they are written and appear on pages 3 and 4.Participant_____________________________________________ Home # ___________________________Date of Birth_______________________ Age _________ Male______ Female_____ Grade ______Participant’s Address_______________________________________________________________________City________________________________________________ State_______ Zip Code____________________Mother/Guardian Name ________________________________ Mother/Guardian Cell__________________Mother/Guardian Work _______________________ Email ________________________________________Father/Guardian Name ________________________________ Father/Guardian Cell__________________Father/Guardian Work _______________________ Email ________________________________________Emergency AuthorizationIn all activities there exists the potential for injury, minimal to catastrophic. Therefore, I authorize KidsAmerica to take whatever emergency medical measures are deemed necessary for the protection of my child, while in the care of KidsAmerica, including calling EMS for transportation to a hospital or clinic. I/We as the parent/guardian assume all financial responsibility for transport and care received.Emergency Contact when parent cannot be reachedName/Relation __________________________________________ Phone #___________________________________Doctor’s Name___________________________________________ Phone #___________________________________List all medications your child is currently taking, allergies, or any other noteworthy medical information _____________________________________________________________________________________Any intolerance to drugs or medication _____________________________________________________________________________________Any previous illness or injury the staff should be aware of ____________________________________________________________________________________Please list any other special information or circumstances our staff may need to be aware of ____________________________________________________________________________________Credit Card InformationCard Number:_____________________________________ Card Expiration Month ________ Year _________Name as it Appears on Card: ______________________________________________________ Assumption of Risk – Wavier of Liability – Photo ReleaseI/ We recognize the potential for injury, minor to catastrophic and am aware of the risk and hazards associated with strength and conditioning exercises, gymnastics, use of gymnastics equipment including but not limited to TumbleTrak, spring floors, spring boards, uneven bars, and balance beams, tumbling, cheerleading, cheer stunting, dance instruction, parties, special events, sleepovers, use of inflatables, parades, camps, recitals, exhibitions, competitions, clinics, and travel to and from events. I/We will make my child (ren) aware of these potential risks and hazards: and, encourage my child (ren) to follow all safety rules. I/We release KidsAmerica Arts & Athletics LLC, KidsAmerica Inc., proprietors, instructors, and sponsors from any and all liability for injuries sustained by any student during the course of strength and conditioning exercises, gymnastics, use of gymnastics equipment including but not limited to TumbleTrak, spring floors, spring boards, uneven bars, and balance beams, tumbling, cheerleading, cheer stunting, dance instruction, parties, special events, sleepovers, use of inflatables, parades, camps, recitals, exhibitions, competitions, clinics, and travel to and from events. I represent and consent for myself, my child (ren), minors and elders in my care to participate in all programs offered by KidsAmerica Arts & Athletics LLC, KidsAmerica Inc., and their representatives whether paid or volunteer. I/We release the KidsAmerica Arts & Athletics LLC, KidsAmerica, Inc., proprietors, instructors, and sponsors from any liability of said above, to us, or to either of us as parents or guardians for injury to above and further agree to indemnify the said KidsAmerica Arts & Athletics LLC, KidsAmerica Inc., proprietors, instructors, and sponsors against all loss and liability which they may incur or become responsible for, arising by virtue of said above’s participation in such activities and athletics.I hereby grant my permission for my or my child’s likeness (including pictures and/or video) to be used in KidsAmerica publicity or advertising. This may include any publications, print, ads, direct mail pieces, social media, electronic media or publication on the World Wide Web site and/or the KidsAmerica Facebook page, and all other forms of media. This release shall continue to be in force until specifically revoked.Parent or Guardian’s Signature _________________________________________________Date______________Parent or Guardian’s Printed Name _________________________________________________________________I have read, understand and agree with all KidsAmerica Policies and Procedures on pages 3 and 4 of thisStudent Registration Form.Parent or Guardian’s Signature_________________________________________________Date_____________How did you hear about KidsAmerica?FaceBookInternet SearchOther ________________________________Referred by: _____________________________________________ (Please let us know if you were referred by a current KidsAmerica Student/Parent so that we may thank them properly.)POLICIES AND PROCEDURESRegistration for all KidsAmerica classes, including Dance, Gymnastics, Cheer/Tumbling, Exhibition, Integrity Courses, and Private Lessons require a separate, yearly $30.00 continuing registration fee, per student, along with a completed four page Student Registration Form, a signed Emergency Authorization, Assumption of Risk and Waiver of Liability and Photo Release, and Policies and Procedures Form. This is a yearly, non-refundable registration fee and will automatically be charged to your account each year in the same month student began classes at KidsAmerica unless KidsAmerica is notified. No child may take a class, UNTIL ALL FORMS are COMPLETED AND SIGNED. We do NOT give your information to anyone for any reason.The online registration process is not a guaranteed spot in class until we’ve received completed forms, payment and you have confirmation of class from our customer service representative.Each family is required to have a credit card or debit card information on file for payment.All tuition is paid monthly. Each month constitutes Four (4) lessons. Tuition is paid each month for the upcoming month. Payments are due according to Tuition Schedule. You are responsible for payments regardless of attendance. NO REFUNDS are granted for classes not attended. It is your responsibility to notify our office staff of any changes for accounting purposes. Instructors and other personnel are not responsible for relaying any accounting information.Please note: you have the option to make payments as follows: Use your credit/debit card on file and automatically be charged every month according to the Tuition ScheduleCash or Check: please make checks payable to KidsAmerica. Please write student’s first and last name in the memo of check.You may mail payments to: KidsAmerica, PO Box 1034, Perry GA 31069.Visa/Mastercard/Discover/American Express in our office or over the phone****When payments are not made, by date noted on Tuition Schedule, the balance of your account will be electronically charged to your credit/debit card on file the 10th of the month. No statements will be mailed or emailed unless requested. Our Office Staff is always happy to answer any questions. ****6. KidsAmerica fee charged: Credit Card Declined = $10 decline fee, Returned checks = $35 returned check fee 7. Classes are not held for some holidays. Each child will be notified in advance. All payments are due with no exceptions for Fall Break, Thanksgiving Break, Winter Break, and Spring Break, illness, or any other reason. Absences may not be accumulated. Absences may be rescheduled within one (1) month if a comparable class is available. If your child attends more classes than scheduled, she/he will be charged for the extra lessons.8. Placement of students is up to the Studio Leader’s discretion.9. Students may not bring friends to “participate” in any class. There are no exceptions.10. The definition of a private lesson is 1 to 3 students with 1 instructor in our facility. There may be other classes in the facility during this time.11. Please do not bring students to class early or pick them up late, as we do not have anyone to sit with them. Our instructors are not responsible for any children before or after class. 12. No child is required to perform inside or away from KidsAmerica facility. All money for costume and tuition must be paid in full through the end of the year before costumes will be sent home. 13. KidsAmerica is not responsible for any loss of personal property or valuables.POLICIES AND PROCEDURES14. KidsAmerica? Arts & Athletics LLC, KidsAmerica? Inc., choreography, recorded music, DVDS, instructional videos, written or vocal instruction, booklets, Polly Pigtails ? name and picture, Paul on the Hall ? name and picture and/or merchandise are copyrighted and the property of KidsAmerica? Arts and Athletics LLC, KidsAmerica? Inc. Videotaping your child is welcome.15. KidsAmerica Arts & Athletics LLC and KidsAmerica Inc. reserve the right to cancel a student’s registration at any time.16. KidsAmerica Arts & Athletics LLC and KidsAmerica Inc. reserve the right to cancel any class or classes, temporarily or indefinitely and without prior notice.17. KidsAmerica information will be sent to you via email. Please make sure we have your correct email address on file.18. Any changes in classes, due to inclement weather, will be posted to: KidsAmerica Facebook page and/or .19. All policies, rates and fees are subject to change as conditions warrant. I understand and agree to uphold the policies and procedures as stated above. ................
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