Jump Indoors Enrollment & Registration Form This form must be completed and submitted to Jump Indoors at the time of registration. PLEASE PRINT CLEARLY * A activity/registration fee of $25.00 is due with this registration form Child’s Name: ___________________________________  Date of Birth:___________ Child’s Social Security Number: _____/___/______ Sex: M / F Child’s Age at Admission: ________ School: ________________________________ Grade: ____ Teacher: ____________ Height: ___________ Weight: ___________ Hair: __________ Eyes: __________ Identifying marks: ______________________________________________________ Known Allergies: _______________________________________________________ Please list any medications your child is taking: _______________________________ _____________________________________________________________________ Is there documentation of a physical exam, immunization record, and lead screening on file at your child’s school? Yes No List below any special limitations or concerns your child may have, including dietary restrictions, chronic health conditions, etc. : __________________________________ _____________________________________________________________________ Please list any special interests your child may have: ___________________________ _____________________________________________________________________ Mother’s Name: ____________________________ Home Phone: ______________________ Cell Phone: ______________________ Address: _____________________________________________________________ Employer: _____________________________ Work Phone: ___________________ Father’s Name: _____________________________ Home Phone: ______________________ Cell Phone: ______________________ Address: _____________________________________________________________ Employer: _____________________________ Work Phone: ___________________ Child resides with: Mother Father Both Person responsible for payment: _______________________________ I Understand that my child or children must be picked up by 6:00 p.m. or there will be and additional charge. Yes Initial _____________   Is your child on a behavior plan at school? Yes No If yes, please explain: ___________________________________________________ Does your child have a 1 on 1 aid at school? Yes No Does your child require an aid outside of school? Yes No If yes, please list aid’s name and agency’s information: _________________________ _____________________________________________________________________ List any other information you would like to give us to help better care for your child: _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ Days Child Will be Attending: Mon ___ Tues ___ Wed ___ Thurs ____ Fri ____ The Jump Indoors After School Program adheres to a non-discriminatory policy as to members and students. I hereby release Jump Indoors and its employees from liability in the event of an accident to me child, except in the case of gross neglect. I hereby give permission for my child to be administered first aid, and if the employees of Jump Indoors feel it is necessary, that my child be treated at the closest hospital. Please read and circle: 1. I give Jump Indoors permission to use photographs of my child for display/program purposes. Yes No 2. I give Jump Indoors permission to transport my child from school in a licensed van or bus to Jump Indoors. I give Jump Indoors permission to transport my child from Jump Indoors on Field Trips.      Yes No 3. My child needs a booster/car seat when transported (must be 6 years old and at least 60 pounds to be exempt). Yes No Please initial which applies to you and your child: _____ There are no custody issues regarding my child. If at any time this status changes, I am responsible for providing a copy of custody papers to Jump Indoors. If I do not, I understand that my child may be released to either parent or persons listed on the emergency contact form. _____ I have given Jump Indoors a copy of the latest custody papers for my child. I am also aware that it is my responsibility to furnish any updated custody papers. If I fail to do so, the latest papers on file will be enforced. Parent Signature: ________________________________ Date: _________________