2nd Child's information (Click arrow to enter information) >>>
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:
Grant permission for Club K staff to take whatever steps may be necessary to obtain emergency medical care if
- To wear face-covering for required parts of the day
- To participate in Wellness Screening daily which includes temperature monitoring
- To participate in necessary screen time related to comprehensive distance learning activities;
- Adhere to Club K's travel restrictions as outlined in the Health Screen Form;
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 acknowledge and agree 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.
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
- Medical Protocol
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