2022 Summer Camp Registration

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Tiny Notes Enrichment Center

Child's Name *

Gender *

Male

Female

Prefer not to say

Child's Date of Birth *

YYYY

Parent/Guardians Full Name *

Parent/Guardians Phone Number *

Email Address *

Does your child have any allergies or medical conditions? *

Does your child have an IEP? *

Yes

Is your child potty trained? Do they need any sort of assistance in the bathroom?

Any special accommodations needed?

Up to date on vaccinations? *

Pediatricians Name & Number *

Do you need a payment plan? Only all weeks can be broke up. It will be split in 2 payments *

Yes I do

No I do not

What time option do you want? *

10am-12:30pm

How did you hear about us? If from a friend or family, who referred you?

Emergency Contact #1 Name & Phone Number *

Emergency Contact #2 Name & Phone Number *

List of any other contacts allowed to pick up my child. (Name & Number) *

Is there any court or custody documents that we need to be aware of? Example: If a parent is not allowed to pick up?

Yes

Clear selection

I consent to allow my child to be included in photos taken during summer camps that may be used for Tiny Notes Music & Movement LLC media accounts and marketing. *

I agree

I do not agree

I understand that payment is due at the time of registration. A square invoice will be emailed to me within 24 hours. *

I agree

I understand that if I decide to withdrawal my child from Tiny Notes Summer Programs, tuition is non refundable. *

I understand

Pick-up, please pick up your child at their scheduled time to be picked up, promptly. A late fee of $1 a min will be charged, If a true emergency happens, please call 360-443-2399 to notify staff you will be late. *

I agree

I give Tiny Notes Music & Movement LLC consent to seek and accept medical treatment for my child. *

Agree. (By checking this box, the above parent or guardian agrees to consent to treat)

I do not agree.

Additional Comments/Concerns?

Waiver and Release of Liability I agree that this Waiver and Release of Liability shall apply to each day I am at Tiny Notes Music and Movement LLC regardless of the date that this form is signed below.This form does not apply to regular class times where staff is responsible for my child. This form is intended for when the children are in parents care on the premises. I agree I will assume the risk and full responsibility for any and all injuries, losses, or damages, that might occur to my child or other family members while on the premises of the preschool or participating in any off-site preschool program or activity; and to the maximum extent of the law, I agree to waive and release any and all claims, suits, or related causes of action against Tiny Notes Music and Movement LLC their owners, officers, employees or agents for injury, loss, death, costs or other damages to me, my heirs or assigns, or third party claims, suits or related causes of action asserted against the preschool arising from my conduct and/or my family’s conduct while participating in the preschool’s programs or activities. I further agree to release, indemnify, defend and hold Tiny Notes Music and Movement LLC harmless from any liability whatsoever for future claims presented by my child for any injuries, losses or damages. *

I agree. By checking this box the above named parent or guardian agrees to terms and conditions of the liability waiver.

Thank you for joining Tiny Notes Music and Movement LLC. By typing your full name below and submitting this form you are verifying that all of the submitted information above is true and that you are the parent or legal guardian authorized to grant permission for the child to participate. *

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