LSAC Kids Club PlaySchool Registration Please fill out the registration form below and someone will be in touch with you shortly. Leave this field empty. Child Registration Child's Name (required) Child's Age (required) Date of Birth (required) Parent/Guardian Name (required) Email Address (required) Primary Contact Phone Number (required) Emergency Contact (required) Emergency Contact Phone Number (required) Please Select Day(s) Monday Tuesday Wednesday Thursday Friday Monday * Music * 9:15 Guitar Circle 10:00 Lil' Mozarts Tuesday * Imagination * 9:15 Under the Big Top 10:00 Lil' Explorers Wednesday * Movement * 9:15 Do a Li' Dance 10:00 Lil' Stretchers Thursday * Letters & Numbers * 9:15 Magic Numbers 10:00 Lil' Learning Bugs Friday * Language * 9:15 Lil' Librarians 10:00 Tiny Travelers Pricing 1x/week: $50 per child 2x/week: $60 per child 3x/week: $75 per child Sibling Discount : $20 off total billing Kids Club Policies Children must be picked up by 11:00am by the same adult that dropped them off unless a Child Release Form is signed. Photo ID will be required upon pick up. Due to allergies, food and gum are not permitted. Kids Club Wellness Policy – please do not bring your child if they are showing any of the following symptoms: fever, vomiting, diarrhea, excessive nasal discharge, rash, pink eye, excessive coughing or sore throat. We reserve the right to refuse admittance at our own discretion and to interrupt your workout if your child is exhibiting any of the above symptoms while at Kids Club. Parents will be called upon to deal with extreme behavior (biting, excessive aggression towards others, three time-outs) and illness. Parents must remain on club premises. Please include any and all allergy information for your child/ren in the provided space. Non-potty trained children should arrive in a fresh diaper; please provide extra diapers and wipes for use during this event. Please provide a change of clothes for children who are potty training. Activity Waiver (required) You agree that you are aware that the child/ren named may be engaging in play and/or physical activity involving various sports, coordination events, general fitness training, and movement, which could cause injury to him or her. You understand that the child is voluntarily participating in these activities and is assuming all risks of injury that may result from engaging in any exercise program or sport related event including tripping, slipping, or falling, on or off the club premises, even if the Chicago Athletic Clubs or its officers, directors, employees or agents, through negligence or otherwise, might be deemed liable. You hereby release, waive, discharge and covenant not to sue Chicago Athletic Clubs or its officers, directors, employees or any agents, coaches, participants, sponsoring agents, sponsors, advertisers or others associated with Chicago Athletic Clubs and, even if the liability arises out of negligence that may not be foreseeable at this time. This release shall be effective even though said loss, damage or injury results or has resulted from the negligence, wrongful acts, omissions, breach of warranty or strict tort liability of Chicago Athletic Clubs. You understand that we will make no evaluation or recommendation as to whether or not the child is capable or deemed physically fit to engage in any activity. If the child has any physical or mental condition that may impair his or her ability to engage in any of the club activities, it is your responsibility to obtain a physician’s release statement. It is recommended you consult a physician prior to your child participating in any physical exercise program. In the event that a medical emergency concerning your child should occur, you hereby grant permission to the club to obtain emergency medical care for your child and agree to waive any claim against the club, our employees, owners, officers, or agents for any injury that may occur through the use of emergency medical services. You agree and you are aware that your child may be participating in activities involving the handling and consumption of food and that this food may contain wheat, soy, dairy, eggs, and/or gluten. You understand that the child is voluntarily participating in these activities and is assuming all risks of injury that may result from engaging in any food-related activities. You hereby agree to waive any claims or rights that you might otherwise have to sue the club, our employees, owners, officers, or agents for any injury or illness that might occur while you are off club property. I have read and agree to the Activity Waiver. Medical Waiver (required) I hereby understand that this medication will be administered in good judgment and with ethical practice. I understand the possible consequences in the administration of the medication listed below. In consideration of administering said medication, I hereby release, waive, discharge and hold harmless Lincoln Park Athletic Club and its employees from any claims, demands, or suits for damages from any injury or complication which may result from the administration of the below-mentioned medications to my child, named in this registration form. I have read and agree to the Medical Waiver. Allergies (required) My child is not allergic to anything. My child has allergies and/or requires medication, which I have listed below. Medications Please list all allergies, symptoms, and medication required for your child. Policies and Procedures Acknowledgement My electronic signature acknowledges that I have read and agree to the terms and conditions of LSAC Kids Club PlaySchool, especially the Kids Club Wellness Policy. I understand there are no refunds or transfers without exception and have read and agree to the above waivers. I authorize Lincoln Square Athletic Club to charge my credit card that is on file the total charge for Kids Club PlaySchool services and post to my account – all sales are final. I understand and agree to all Kids Club policies.