Bestow Schools | WHACK Kidz Registration

WHACK Kidz Application

Name of Child

First

Middle

Last

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Age

Sex

Birth Date

Anticipated Start Date

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Father/Guardian

Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone

Cell Phone

Email

Confirm Email

Employer

Occupation

Mother/Guardian

Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone

Cell Phone

Email

Confirm Email

Employer

Occupation

Individuals authorized to pick up my child or for emergency contact

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Name

Relation

Single Line Text

Home Number

Numbers

Work Number

Numbers

Health History

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Name of Family Physician

Address

Address Line 1

Address Line 2

City

State

Zip Code

Date of last physical exam

Operations of serious illness

Disability or recurring illness

Activities limited by a physician

Dietary modifications

Allergies

Telephone

Which of the following has your child had?

Use this space to provide any additional information about your children that we should be aware of:

Waiver

This health history is complete and accurate, and participant has permission to engage in all activities unless otherwise specified in writing. I understand that, “Bestow School/Bestow ELC/WHACK Kidz,” assumes no responsibility for injuries or illnesses which my child may sustain as a result of his/her participation at the, “Bestow School/Bestow ELC/WHACK Kidz,” I expressly acknowledge that my child has been medically cleared to participate in rigorous physical activities. I also understand that there is a risk of injury while participating in physical activity by my child. I agree to hold harmless the , “Bestow School/Bestow ELC/WHACK Kidz,”, its staff and volunteers for accidents or injuries arising out of his/her participation in any activity.

I agree to have my child examined, prior to enrollment, within a reasonable time period by the family physician stating he/she is free of communicable disease and has not been exposed to such. In the event that I cannot be reached in an emergency, I hereby give permission to the physician selected by The, “Bestow School/Bestow ELC/WHACK Kidz,” Director to secure and administer treatment including hospitalization for my child. I understand that no accident or medical insurance is provided by , “Bestow School/Bestow ELC/WHACK Kidz,” and I will be responsible for any and all charges related to my child’s care.

Media Release

I give permission to the BESTOW SCHOOLS & ELC, without limitation or obligation to use photographs, film footage, social media, or tape recordings which may include my child’s image or voice for purposes of promoting or interpreting “BESTOW SCHOOLS & ELC,” programs and release “BESTOW SCHOOLS & ELC,” from any claim of liability.

Field Trip Release

I give my consent for my child to leave the “, “Bestow School/Bestow ELC/WHACK Kidz,” site to participate in field trips, including walking field trips, and to ride in authorized vehicles for the purpose of transportation in connection with the “BESTOW SCHOOLS & ELC program.

I HAVE READ AND AGREE TO ALL THE POLICIES SET FORTH BY THE BESTOW SCHOOLS & ELC PROGRAM.

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Signature

Today's Date

Parental Agreement

Payment Schedule

1. In return for services I receive, I agree to pay to amount of $150 weekly on Friday of each week. Fees should be made payable to: BESTOW SCHOOLS & ELC. All fees must be paid prior to attending BESTOW.

2. I understand that ALL application & supply fees are non-refundable.

3. I have read the Parent Handbook and Information and agree to abide by all the policies and procedures listed.

4. I hereby release , “Bestow School/Bestow ELC/WHACK Kidz,” from any liability for injuries or illnesses resulting from conditions or circumstances beyond the control of , “Bestow School/Bestow ELC/WHACK Kidz,”.

5. I understand that , “Bestow School/Bestow ELC/WHACK Kidz,” will assume responsibility for my child ONLY when he/she is delivered into the center and is acknowledged by the center personnel.

6. AUTHORIZATION FOR EMERGENCY MEDICAL CARE: In the event that I cannot be reached to make arrangements for emergency medical care at the time of illness or accident, I hereby authorize , “Bestow School/Bestow ELC/WHACK Kidz,” to administer any emergency treatment deemed necessary by licensed, trained medical personnel called to BESTOW and/or take my child to the nearest licensed hospital.

I have read and fully understand statements numbered 1, 2, 3, 4, 5 & 6.

1. In return for services I receive, I agree to pay $300, bi-weekly every other Friday of the month. Fees should be made payable to: BESTOW SCHOOLS & ELC. All fees must be paid prior to attending BESTOW.

2. I understand that ALL application & supply fees are non-refundable.

3. I have read the Parent Handbook and Information and agree to abide by all the policies and procedures listed.

4. I hereby release , “Bestow School/Bestow ELC/WHACK Kidz,” from any liability for injuries or illnesses resulting from conditions or circumstances beyond the control of , “Bestow School/Bestow ELC/WHACK Kidz,”.

5. I understand that , “Bestow School/Bestow ELC/WHACK Kidz,” will assume responsibility for my child ONLY when he/she is delivered into the center and is acknowledged by the center personnel.

6. AUTHORIZATION FOR EMERGENCY MEDICAL CARE: In the event that I cannot be reached to make arrangements for emergency medical care at the time of illness or accident, I hereby authorize , “Bestow School/Bestow ELC/WHACK Kidz,” to administer any emergency treatment deemed necessary by licensed, trained medical personnel called to BESTOW and/or take my child to the nearest licensed hospital.

I have read and fully understand statements numbered 1, 2, 3, 4, 5 & 6.

1. In return for services I receive, I agree to pay $600, monthly on the first day of each month. Fees should be made payable to: BESTOW SCHOOLS & ELC. All fees must be paid prior to attending BESTOW.

2. I understand that ALL application & supply fees are non-refundable.

3. I have read the Parent Handbook and Information and agree to abide by all the policies and procedures listed.

4. I hereby release , “Bestow School/Bestow ELC/WHACK Kidz,” from any liability for injuries or illnesses resulting from conditions or circumstances beyond the control of , “Bestow School/Bestow ELC/WHACK Kidz,”.

5. I understand that , “Bestow School/Bestow ELC/WHACK Kidz,” will assume responsibility for my child ONLY when he/she is delivered into the center and is acknowledged by the center personnel.

6. AUTHORIZATION FOR EMERGENCY MEDICAL CARE: In the event that I cannot be reached to make arrangements for emergency medical care at the time of illness or accident, I hereby authorize , “Bestow School/Bestow ELC/WHACK Kidz,” to administer any emergency treatment deemed necessary by licensed, trained medical personnel called to BESTOW and/or take my child to the nearest licensed hospital.

I have read and fully understand statements numbered 1, 2, 3, 4, 5 & 6.

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Signature

Today's Date

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WHACK Kidz Registration

Please upload the following:

WHACK Kidz Application

Father/Guardian

Mother/Guardian

Individuals authorized to pick up my child or for emergency contact

Name

Relation

Home Number

Work Number

Health History

Waiver

Media Release

Field Trip Release

Parental Agreement

T-Shirt Order Form

Payment