Play On! Wavier & Registration 2023-2024
Executive Arts, LLC DBA Play On! does not provide refunds or credits for absences or withdrawals unless the program is cancelled by Executive Arts. This form is valid through August 14, 2024.
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Host School *
Student First Name *
Student Last Name *
Student Birthdate *
MM
/
DD
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YYYY
Student Grade *
Teacher *
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 in 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 if different
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
As a parent registering their child for a Play On! providing in-person class, you agree and understand the following: By participating you agree to fully accept all known and unknown risks, including the potential risk of exposure to respiratory illnesses such as the coronavirus (COVID-19). This coronavirus is primarily transmitted via exhaled respiratory droplets, most often through coughing and sneezing. These droplets can travel up to six feet and are more commonly transmitted between persons. Students are required to follow school protocols for mask wearing and social distancing. Known coronavirus symptoms include fever, coughing, shortness of breath, pneumonia, and may include other symptoms, stroke or even death (collectively "Symptoms"). You understand and agree that you will hold Play On!  harmless and you will not hold Play On!  liable for any real or perceived symptoms of COVID-19 or any other disease, illness, or condition, nor for exacerbating any existing symptoms. You fully agree to accept all risks by entering the school and participating in class .You understand that you may be exposed to the coronavirus or its symptoms through no fault of Play On ! . *
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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