Camp Pump It Up Registration Form

Transcription

1 Camp Pump It Up Registration Form Parent/Guardian Name: Child s name: Birth Date: Child s name: Birth Date: Child s name: Birth Date: Address: Address: Other adults authorized for pick up: Best phone number to reach you at: Emergency Contact other than yourself (name/number): Alternate phone: Do you authorize a camp staff member to call 911 or take your child to the nearest hospital if an emergency were to occur? Yes No Does your child have any allergies or special needs or friends to be partnered with? If so, please list them. Where did you hear about us? Enter any promotional discounts if applicable: Payment Information: Full payment required upon sign up. VISA MasterCard Will call with payment information Groupon Cash Groupon Voucher Number Card Number: Exp. Date:

2 Session(s) campers will attend Half Day: 9am - 12:30pm Full Day: 9am 3:30pm Weeks Mon Tue Wed Thu Fri Full Week 7/6-7/10 7/13 7/17 7/20 7/24 7/27 7/31 8/3 8/7 8/10 8/14 8/17 8/21 8/24 8/28 Camp Session Fees: Half Day:$25/session Full Day: $40/day Weekly Rate: $175 *** Siblings always receive a 10% discount *** CAMP POLICIES: Camp Dates: must be selected at registration and cannot be moved or changed. Missed Days: cannot be made up or refunded. Snacks & Lunch: are not provided and must be brought in. (please no peanut products) Registration: 24hr notice for camp registration is required THIS SECTION MUST BE READ THROUGH AND COMPLETED BY PARENT OR GUARDIAN OF CAMPER BEFORE REGISTRATION As Consideration for being allowed to enter the play area and/or Participate in any party and/or program at Pump It Up the undersigned, on his or her behalf, and on the behalf of the Participant(s) identified below, acknowledges, appreciates, understands, and agrees to the following: 1. I represent that I am the parent or legal guardian of the Participant(s) named below or I have obtained permission from the parent/legal guardian of the Participant(s) named below to execute this agreement on their behalf. 2. I acknowledge and understand that there are known and unknown risks associated with participation in Pump It Up activities and the use of the play area, inflatable equipment and any and all other Pump It Up equipment, including but not limited to the Pop-In Playtime and Open play, which include but are not limited to: contusions, fractures, scrapes, cuts, bumps, paralysis, or death. 3. I, for myself and the Participant(s) named, willingly assume the risks associated with participation and accept that there are also risks that may arise due to OTHER PARTICIPANTS which I also willingly assume. 4. I agree that the Participant(s) named, and I shall comply with all stated and customary terms, posted safety signs, rules, and verbal instructions as conditions for participation in any Pop-In-Playtime and/or any other open play event at Pump It Up. 5. I, for myself, the Participant(s) named, our heirs, assigns, representatives, and next of kin agree to hold harmless, release, waive and indemnify the independent owner of this Pump It Up facility, PIU Holdings, LLC, their predecessors, parent, subsidiaries and affiliates, officers, and employees from any and all injuries, liabilities or damages from participation, except for those arising from the gross negligence or willful misconduct of Pump It Up. 6. I additionally agree to indemnify the independent owner of this Pump It Up facility, PIU Holdings, LLC, their predecessors, parent, subsidiaries and affiliates, officers, and employees for any defense cost or expense arising from any and all claims, injuries, liabilities or damages arising from participation, except for those arising from the gross negligence or willful misconduct of Pump It Up. 7. I am of physical ability to participate and am legally competent to understand and complete this agreement. I hereby execute this agreement without coercion. 8. I understand that entry, by myself and the participant(s) named, constitutes consent for Pump It Up to use any film, video, or likeness of participants for any purpose whatsoever, without payment to the participant. 9. The invalidity or unenforceability of any provision of this Agreement shall not affect the validity or enforceability of any other provision of this Agreement, which shall remain in full force and effect. 10. Any controversy, dispute, or claim arising out of or related to this Agreement, which the parties are unable to resolve by mutual agreement, shall be settled exclusively by submission by either party of the controversy, claim or dispute to binding arbitration; said arbitration to take place exclusively before a single arbitrator located within 25 miles of the Event location and in accordance with the rules of the American Arbitration Association then in effect. Parent/Guardian Name Parent/Guardian Signature Date

3 Camp Guidelines To ensure a safe, enjoyable environment for everyone, the information below outlines our guidelines. These are subject to change with or without notice. The program is from 9:00am-3:30pm on the days appropriate for the program or as outlined by the event that you signed up for. Please have your child picked up no later than 3:30pm. A $5 late fee will occur for the first 30 minutes and $5 each additional 30 minutes. The program involves the following schedule that may or may not occur in this order - Art, music, crafts, jumping, stories, games and special character visit Snacks - Children should bring a healthy snack for the morning and a fun snack for the afternoon. Snacks may also be purchased on-site for your convenience. We have water fountains throughout the facility. Lunch starts between 12:00-12:15pm. Please assure that peanut products are avoided for the safety of all children. Please be sure to label anything brought in with your child s full name. All children must be fully potty trained. Ages 4-11 are preferred but not limited to. Each child must bring or wear a pair of socks. Please do not bring any other personal belongings (other than lunches) as we cannot be responsible for lost or stolen items. Sorry, no refunds or make up days allowed for missed days of camp. There are no refunds for children that are removed from the program due to any behavior that is harmful to other children, persons or themselves. Please do not bring your child if they are sick. We will not allow children that are sick to be dropped off; any child that becomes ill during the program will need to be picked up as well. All children will need to be signed in AND out by an approved parent/guardian each day. The signin/out sheet will be in the lobby or pick-up arena. A photo ID will be required at pick-up. Please send your child in old clothing; although all products we work with are non-toxic waterbased products, we cannot guarantee staining will not occur. Extra clothing may be sent in daily. Parent s Child s Name: By signing these guidelines you also give permission to Jump-N-Art to photograph your child for the camp website and promotional uses. If you do not wish for your child s picture to be used in any manner please check here:

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5 Pump It Up Photo Waiver I,, the parent and/or legal guardian of, (my Child ), do hereby grant permission to PIU Management, LLC to photograph and to publish the photographs of me and/or my Child on the PIU Management, LLC website and in related PIU Management, LL promotional brochures and videos for the purpose of promoting PIU Management s business. I hereby waive all rights of privacy and/or compensation for me or my Child, which I, or she/he, may have in connection with the use of my, or her/his, photograph or likeness, or any or all of them, in or in connection with said web sites, still photography, or film and any use to which the same or any material therein may be put, applied or adapted by PIU in connection with the promotion of PIU Management s business. I, for myself and my Child and our respective heirs, administrators, successors and assigns hereby release PIU from and against any and all claims, liabilities or damages arising out of, or in connection with, the use of my, or my Child s, photograph or likeness, or any or all of them, by PIU Management, LLC for its business promotion activities. Name: Parent and/or Legal Guardian of: Date: (Child s name)

6 Pump It Up Testimonial Waiver - CHILD I,, the parent and legal guardian of hereby grant permission to PIU Holdings, LLC, to publish my child s (or children s) written and/or verbal testimonial(s) on the Pump It Up website and/or in related Pump It Up promotional brochures and/or videos for the purposes of promoting the Pump It Up businesses. I hereby waive all rights of privacy and/or compensation for myself and my child (children), which I may have in connection with the use of my testimonial(s) as relating to the Pump It Up website and/or related Pump It Up promotional brochures and/or videos with regard to the promotion of the Pump It Up businesses. I, for myself, my child (children), my heirs, administrators, successors and assigns hereby release PIU Holdings, LLC from and against any and all claims, liabilities or damages arising out of, or in connection with, the use of my child s (children s) testimonial(s), by PIU Holdings, LLC for its business and promotional activities. I warrant that I am over 18 years of age and have read this release and understand its contents. This release shall be binding upon me, my child (children), my heirs and assignees. Name: Parent or Legal Guardian of: (Child s Name) Date:

7 Pump It Up Testimonial Waiver I, hereby grant permission to PIU Holdings, LLC, to publish my written and/or verbal testimonial(s) on the Pump It Up website and/or in related Pump It Up promotional brochures and/or videos for the purposes of promoting the Pump It Up businesses. I hereby waive all rights of privacy and/or compensation for myself, which I may have in connection with the use of my testimonial(s) relating to the Pump It Up website and/or in related Pump It Up promotional brochures and/or videos with regard to the promotion of the Pump It Up businesses. I, for myself and my heirs, administrators, successors and assigns hereby release PIU Holdings, LLC from and against any and all claims, liabilities or damages arising out of, or in connection with, the use of my testimonial(s), by PIU Holdings, LLC for its business and promotional activities. I warrant that I am over 18 years of age and have read this release and understand its contents. This release shall be binding upon me, my heirs and assignees. Name: Date: