Confident Kid Club Student Registration

Confident Kid Club Student Registration

Please fill out the form below, check the authorization box, and click “Register” to begin your registration process. Once your registration is complete, please be sure to arrange for payment.

(Please note: an asterisk denotes a required field.)

 

Parent/Guardian Information

Parent/Guardian Name*:

Address*:




Primary phone*:

Work phone:

E-mail:*

 

Additional Parent/Guardian Info

Name:

Address:




Primary phone:

Work phone:

E-mail:

Additional Adults Authorized to Pick Up Child:


 

Student Information

Social Skills Program*:

Student Name*:

Student Date of Birth*:

Additional Information:

Emergency Contact*:


Primary Physician*:


 

Related Information

I am enrolling my child because:

What are your child’s interests? (Toys, games, books, action figures,
sports, music, etc.):

What are your child’s strengths?:

 

Acceptance of Terms

I hereby cofirm that I am the legal guardian of the student named above and
hereby give consent for my child to participate in Confident
Kid Club, LLC’s programs. I agree to release, hold harmless and waive all
claims and causes of action that may hereafter accrue to me against
Confident Kid Club, LLC, the co-founding partners and substitute instructors
associated with any injury that may be caused as a result of any action other
than the sole negligence of Confident Kid Club, LLC, and the co-founding
partners and substitute instructors. I further agree to indemnify and hold
harmless Confident Kid Club, LLC, the co-founding partners and substitute
instructors, from any action or inaction of my child that may cause any injury
or damage whatsoever. I hereby give full permission for my child to
participate in all activities and agree to notify group leaders of any
precautionary measures that should be noted or taken during group classes.
In the event of any injury to my child, I hereby grant full power of attorney
to Confident Kid Club, LLC, the co-founding partners and substitute
instructors to obtain any emergency medical treatment they (in their sole
discretion) deem necessary in the best interest of my child. I will assume
responsibility for fees incurred by such an emergency.

(Please check box to accept the above terms.)

Legal Parent/Guardian Authorized e-Signature*:

Today's Date*: