Action Potential Lab - General Information Form - PA Day
Hello! We require the following information about our students to ensure we are aware of contact information, food allergies, special needs, etc

Thank you for taking the time to fill it out.

-Your friends at Action Potential Lab

Child's Information
Child's Name
Your answer
Child's Age
Your answer
Date of Birth
Your answer
Gender
Your answer
Which school does the child attend?
Your answer
Which grade is the child in?
Your answer
Program
Name of Action Potential Lab program you are enrolling in:
Your answer
How did you hear about Action Potential Lab?
Your answer
Contact Information
Parent/Guardian's name:
Your answer
Home Address:
Your answer
Email:
Your answer
Home Phone Number:
Your answer
Cell Phone Number:
Your answer
Emergency Contact A:
Name
Your answer
Email
Your answer
Contact #
Your answer
Emergency Contact B (if applicable)
Name
Your answer
Email
Your answer
Contact #
Your answer
Program Pick up
Please list the contact information of parents/guardians who will be picking up your child after class

**Your child will not be permitted to be picked up by someone who is not on this list. Should there be a change to this list, you must inform Action Potential Lab by email or telephone beforehand. **

Name
Your answer
Contact #
Your answer
Relationship to Child
Your answer
Name
Your answer
Contact #
Your answer
Relationship to Child
Your answer
Behaviour and Learning Style
Please let us know of there is a specific learning need or learning style for your child. This information is important for our instructors to know ahead of time, so as to give your child the best experience possible while attending our programs.
Your answer
Medical Information
Please list any allergies, medications, special needs or medical concerns that Action Potential Lab should know about:
Your answer
Name of Doctor:
Your answer
Contact Number for Doctor’s office:
Your answer
Parks, Splash Pad and Snacks Permission
All Hillcrest Park visits will be accompanied by camp staff, this includes crossing the street and all activities inside the park. Whenever campers and camp staff members are outside of the lab, one camp staff member will have a safety bag on them, which includes a whistle, a first aid kit, campers’ epipens or prescribed medications and emergency contact numbers for each child.
Park Permission *
I/we give permission for my child to play in Hillcrest Park, which is directly across the street from Action Potential Lab.
Required
Splash Pad Permission *
I/we give permission for my child to play in the splash pad which is located in Hillcrest Park.
Required
Snack Permission *
I/we give permission for Action Potential LTD to offer my child a nut-free, vegetarian snack or juice throughout their time at camp. Please notes that all snack given will abide by the allergies and request made by parents/guardians in their child’s General Information Form above.
Required
Policy
Students must be registered 1 week prior to the commencement of the first class. Students will not be able to participate in the class until the General Information Form is filled out and submitted. Once payment is received, a confirmation will be emailed to you. Receipt of payment and General Information Form (this form) secures your child's place in the class.There are no makeup classes or refunds for missed classes. Refunds will not be given after the first class. Action Potential Lab reserves the right to cancel any event should group size be below minimum attendance.
Agreement
I give permission for my child to participate in the class held at Action Potential Lab.

I give permission for staff of Action Potential LTD to use his/her best judgment in obtaining the necessary medical care for my child if required. I understand that in the case of such a medical event, illness or injury, I will be notified as soon as possible.

Action Potential LTD reserves the right to use pictures or videos and materials of students and their projects for advertising or promotional purposes. If you do not want your child, yourself, or family member to be photographed, please let us know.

I understand that all of the information above is to be kept on file for the safety of my child and for the purpose of Action Potential LTD. I am aware that this information will never be shared outside of Action Potential LTD.

I hereby release Action Potential LTD, its owners and operators from all liability and all claims for damages relating to any loss, accident, injury, including death, that may be sustained by my child while in or upon the premises or any premises under the control and supervision of Action Potential LTD. I will not make claim against, sue or attach the property of Action Potential LTD, its owners and operators.

Parent/Guardian name
Your answer
Date:
Your answer
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