Consent Form

I certify that I am the parent or legal guardian of the student(s) named above. By signing below I agree to the following and give permission for my child to:

• Use all age appropriate equipment and participate in all activities provided by the program.
• Participate in field trips or excursions by bus as well as on neighborhood walking excursions. I understand that if my child does not have permission to attend all the program field trips, I will need to make alternate childcare arrangements on those days.
• Be photographed and videotaped by Club K staff for marketing and staff training purposes including social media, website, brochures, displays, bulletin boards. I understand that no names will be used in photographs.
• View G and/or PG rated movies under Club K After School Zone staff supervision.
• My child(ren) may participate in water play activities. Swimming is a separate program that requires a separate waiver.
• In order to add or delete authorized pick-ups or contacts, an Information Update Form must be submitted to the Main Office prior to the pick-up date. Authorizations must be in writing, verbal authorizations are not accepted.
• There are no persons legally restricted from picking up my child from care or having access to my child. NOTE: If there are, Club K requires court documentation (ex: current court ordered custody agreement, restraining order) prior to your child beginning the program.
• Grant permission for Club K After School Zone staff to apply Rocky Mountain Sunscreen® to my child.
• To exchange information between Club K After School Zone, school personnel and my child’s teacher in the best interest of my child with regard to homework and/or behavior.
• Grant permission for Club K staff to take whatever steps may be necessary to obtain emergency medical care if warranted. These steps may include, but are not limited to the following: a)attempt to contact parent, b) attempt to contact persons listed on the Registration Form, c) in most cases, 911 is called and the child is transported to the nearest hospital and treated by the on-call physician; the parent or guardian of the child is notified immediately.
• Authorize Club K After School Zone staff to take whatever emergency measures (first aid, disaster evacuation or drills, 911 emergency) are deemed necessary for the care and protection of my child. If the situation warrants, I consent to have my child transported and treated by a physician/hospital at my expense. I will assume full financial responsibility for all medical services deemed necessary at that time.
• Agree to release and hold harmless Club K After School Zone, its employees and agents, from any loss or damage to toys, clothes, or other personal items or articles.
• Relieve Club K After School Zone, its employees and agents, of all responsibility for accidents and injuries, claims, damages, or other liabilities for injuries to or damage by my child both on and off the premises which are not a result of gross negligence by the program, its employees or agents.
• The undersigned parent or guardian acknowledges and agrees that neither Club K After School Zone, nor any facilitator or employee of Club K After School Zone shall be held liable for any occurrence in connection with participation in the program that may result in injury or other damage to the participant named above. The undersigned further agrees to indemnify and hold harmless Club K After School Zone and all persons associated with it from any claim arising out of participant’s participation in any recreational, field trip or education program of Club K After School Zone.
• Grant permission to Club K to send alerts and critical updates via text message.

COVID-19 Specific Requirements

1. To wear face-covering for required parts of the day 
2. To participate in Wellness Screening daily which includes temperature monitoring 
3. To participate in necessary screen time related to comprehensive distance learning activities;
4. Adhere to Club K's travel restrictions as outlined in the Health Screen Form;

ACKNOWLEDGEMENT

By typing/signing my name below and electronically submitting my registration to Club K After School Zone, I certify the information is true and correct and I agree to the terms and conditions of my child participating in the Club K After School Zone program.

If you have the following forms, please upload them below:

• Court Order/Custody Order/Parenting Time Order/Restraining Order
• IEP/504
• Medical Protocol