How Many Weeks? *

1 Week

2 Weeks

Choose *

Fine Motor Fun

Kickstart Kindergarten

Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Birthday *

MM

DD

YYYY

Parent/Guardian Name 1 *

First Name

Last Name

Phone *

(###)

###

####

Parent/Guardian Name 2

First Name

Last Name

Phone

(###)

###

####

Emergency Contact 1 *

First Name

Last Name

Phone *

(###)

###

####

Emergency Contact 2

First Name

Last Name

Phone

(###)

###

####

You have my permission to use photos and videos of my child on the Coastal Learning Center media sites. *

Yes

No

Parent Name *

First Name

Last Name

Date *

MM

DD

YYYY

Release of Liability *

1. The risk of injury from the activities involved in this program and its related events and activities is significant, including the potential for permanent paralysis and death, and while particular skills, equipment, and personal discipline may reduce this risk, the risk of serious injury does exist; and, 2. I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE OF THE COMPANY, their officers, officials, agents and/or employees, other participants, sponsoring agencies, sponsors, advertisers, and, if applicable, owners and lessors of premises used for the activity ("Releasees"), or others, and assume full responsibility for my participation; and, 3. I willingly agree to comply with the stated and customary terms and conditions for participation. If, however, I observe any unusual significant hazard during my presence or participation, I will remove myself from participation and bring such to the attention of the Company immediately; and, 4. I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, HEREBY RELEASE, INDEMNIFY, AND HOLD HARMLESS THE COMPANY and their Releasees, WITH RESPECT TO ANY AND ALL NJURY, DISABILITY, DEATH, or loss or damage to person or property, WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE, to the fullest extent permitted by law; and 5. By signing this Agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that I may be exposed to, or infected by, COVID-19 and that such exposure or infection could result in personal injury, illness, permanent disability, or death, and that I HEREBY RELEASE, INDEMNIFY, AND HOLD HARMLESS THE COMPANY and their Releasees. I voluntarily agree to assume all the foregoing risks and accept sole responsibility for any injury or illness may experience or incur in connection with any practice, camps, or events hosted by the Company. I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.

Yes

No

Date *

MM

DD

YYYY

(UNDER AGE 18 AT TIME OF REGISTRATION)

This is to certify that I, as parent/guardian with legal responsibility for this participant, do consent and agree to his/her release as provided above of all the Releasees, and, for myself, my child and our heirs, assigns, and next of kin, I release and agree to indemnify and hold harmless the Releasees from any and all liabilities incident to my minor child's involvement or participation in these pro- grams as provided above, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES, to the fullest extent permitted by law.

Option 1

Option 2

Date *

MM

DD

YYYY