After-School Club Registration Form Parent's Name(Required) First Last Parent's Phone Number(Required)Parent's Email(Required) Emergency Contact Name (Different From Above)(Required) First Last Emergency Contact's Phone Number(Required)Student's Name(Required) First Last Student's Grade(Required)1st2nd3rd4th5thDisclaimer: These clubs are only available to grades 1-5 at this time.Student's Teacher(Required)Does your child have any allergies/medical conditions we need to be aware of?(Required)Is there anything else we need to know about your child?(Required)After-School Club Choice(Required) Gamers Unplugged Club (Tuesdays) RAK (Random Acts of Kindness) Club (Thursdays)Session Preference(Required) Session 1 (August - October) RAK Club Only Session 2 (October - December)Gamers Unplugged Club Price: Session 2RAK Club Price: Session 1RAK Club Price: Session 2Coupon Total Credit Card(Required)American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Expiration Date Month Month010203040506070809101112 Year Year20242025202620272028202920302031203220332034203520362037203820392040204120422043 Security Code Cardholder Name Billing Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Learn More About Timeless Play?(Required) Yes please! No, thank youBy checking the box, you agree to receive occasional emails and/or newsletters from Timeless Play that include information on upcoming events, camps, promotions, etc. I understand that I can unsubscribe at any time.Care Waiver(Required) I agree to the following:I hereby permit Timeless Play to provide care to my child(ren) and agree to release and hold harmless Timeless Play, its officers and/or employees from any and all claims, demands or suits arising out of the club experience including, but not limited to, bodily harm or injury, except only for loss, harms or injury occasioned by intentional misconduct by a Timeless Play employee. In the event that I cannot be reached to make arrangements for emergency medical attention, I authorize the Timeless Play employee to engage emergency services to provide necessary medical treatment.Terms & Conditions(Required) I agree to the following:I understand and agree that all club fees paid are non-refundable regardless of circumstance. Additionally, I understand that Timeless Play is not able to offer refunds or make-ups for missed days. I agree to notify your staff if my child will be absent from any club session via email: play@timelessplay.com as soon as possible. Timeless Play strictly enforces pick-up times. All children must be picked-up NO LATER THAN 4:15pm at the designated pick-up spot. I understand that a $2 per minute late fee will be administered and invoiced and that the fee must be paid before the following scheduled club day or my child may not be able to attend. I also agree to notify Timeless Play in writing if there is any adult that my child should NOT be released to. All participating children are expected to follow rules and directions, be respectful to our staff and to others, and participate in planned activities. Children will receive a verbal warning if behavior needs to be corrected. If a verbal warning does not result in behavioral modification, the child will be removed from group activities for a temporary period of time. In this case, the parent/guardian will be notified during pick-up and we ask that the parent speak with the child about the importance of improving their behavior. If the child continues to exhibit disruptive behavior, we reserve the right to remove the child from the club and will notify the parent/guardian in writing.
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