Play On! Wavier & Registration 2019-2020
Executive Arts, LLC DBA Play On! does not provide refunds or credits for absences or withdrawal unless the program is cancelled by Executive Arts. This form is valid through August 14, 2020.
Host School *
Student First Name *
Student Last Name *
Student Birthdate *
MM
/
DD
/
YYYY
Student Grade *
Teacher *
Student ID used for grant reporting only
Allergies or Medical Conditions *
I give permission for Play on to administer the following medications in the event my child has an allergic reaction. I agree to hold Play On! and its staff harmless for any complications arising from administration of above medical conditions. I agree to supply the medications is accordance with the school's policy so Play On! staff have access. *
Required
Medications
Doctor Name *
Doctor Phone Number *
Does student go to school based after care after Play On!? *
Who will regularly pick up student? *
Regular pick up Phone Number *
Adults authorized to sign student out *
Emergency Contact Name *
Emergency Contact Phone Number *
Parent/Guardian 1 Name *
Parent Guardian 1 Address *
Parent Guardian 1 Phone Number(s) *
Parent Guardian 1 Email *
Parent Guardian 2 Name *
Parent Guardian 2 Address
Parent Guardian 2 Phone Number(s) *
Parent Guardian 2 Email *
I give permission for Play On! to take and use photos of my child participating in class for promotional purposes. *
Required
I give permission for my child to have water based face paint applied *
Required
In the event of an emergency and I cannot be reached, I give permission for Play On! to secure medical treatment for my child. This may include calling 911. *
Required
I give permission for emergency personnel to treat the student named above. I accept responsibility for all medical expenses incurred *
Required
I waive, release and discharge any and all rights and claims for damages against Executive Arts, LLC DBA Play On! and its staff arising or resulting from participation in class/camp. I attest and verify that I have full knowledge of the risks involved in this activity and I will assume those risks for the students named above. *
Required
The statements contained in this form and submission of form represent an electronic signature and acceptance of terms to participate in Play On! programming. *
Required
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