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I certify that I am the parent or legal guardian of the student(s) named above. By signing below I agree to the
following and give permission for my child to:
- Use all age appropriate equipment and participate in all activities provided by the program.
- Participate in field trips or excursions by bus as well as on neighborhood walking excursions. I understand that if my
child does not have permission to attend all the program fieldtrips, I will need to make alternate childcare
arrangements on those days.
- Be photographed and videotaped by Club K staff for marketing and staff training purposes including social media,
website, brochures, displays, bulletin boards. I understand that no names will be used in photographs.
- View G and/or PG rated movies under Club K After School Zone staff supervision.
- My child(ren) may participate in water play activities. Swimming is a separate program that requires a separate
- In order to add or delete authorized pick-ups or contacts, an Information Update Form must be submitted to the
Main Office prior to the pick-up date. Authorizations must be in writing, verbal authorizations are not accepted.
- There are no persons legally restricted from picking up my child from care or having access to my child. NOTE:
If there are, Club K requires court documentation (ex: current court ordered custody agreement, restraining
order) prior to your child beginning the program.
- Grant permission for Club K After School Zone staff to apply Rocky Mountain Sunscreen® to my child.
- To exchange information between Club K After School Zone, school personnel and my child’s teacher in the best
interest of my child with regard to homework and/or behavior.
- Grant permission for Club K staff to take whatever steps may be necessary to obtain emergency medical care if
warranted. These steps may include, but are not limited to the following: a)attempt to contact parent, b) attempt
to contact persons listed on the Registration Form, c) in most cases, 911 is called and the child is transported to the
nearest hospital and treated by the on-call physician; the parent or guardian of the child is notified immediately.
- Authorize Club K After School Zone staff to take whatever emergency measures (first aid, disaster evacuation or
drills, 911 emergency) are deemed necessary for the care and protection of my child. If the situation warrants, I
consent to have my child transported and treated by a physician/hospital at my expense. I will assume full financial
responsibility for all medical services deemed necessary at that time.
- Agree to release and hold harmless Club K After School Zone, its employees and agents, from any loss or damage to
toys, clothes, or other personal items or articles.
- Relieve Club K After School Zone, its employees and agents, of all responsibility for accidents and injuries, claims,
damages, or other liabilities for injuries to or damage by my child both on and off the premises which are not a result
of gross negligence by the program, its employees or agents.
- The undersigned parent or guardian acknowledge and agree that neither Club K After School Zone, nor any facilitator or employee of Club K After School Zone shall be held liable for any occurrence in connection with participation in the program that may result in injury or other damage to the participant named above. The undersigned further agrees to indemnify and hold harmless Club K After School Zone and all persons associated with it from any claim arising out of participant’s participation in any recreational, field trip or education program of Club K After School Zone.
By typing/signing my name below and electronically submitting my registration to Club K After School Zone, I certify the information is true and correct and I agree to the terms and conditions of my child participating in the Club K After School Zone program.
If you have the following forms, please upload them below:
- Court Order/Custody Order/Parenting Time Order/Restraining Order
- Medical Protocol
© Club K After School Zone 2020
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