Register

LIC KIDS REGISTRATION FORM

5-02 50^TH Avenue LIC, NY 11101

www.LICkids.com           info@LICkids.com

Student’s Name:                                                                                                                        

Parent’s Name:                                                                                                                                    

Address:                                                        City:                      State:          

Zip:                      

Phone:                                                Email Address:                                                          

*In addition to Parents (listed above) please list any additional people (and phone #s) who would be permitted to pick up your child from LIC Kids.

Name 1:                                                        Phone Number:                                       ____

Name 2:                                                        Phone Number:                                                

Emergency Contact Name:                                                            Phone:                            

Student’s Age:                                                         Date of Birth:                                        

Classes Information

Class Name:                                                   Class Day and Time:                                       

Class Name:                                                   Class Day and Time:                                       

Pre-School and After School Programs

Days of the week:                                                                                                                       

School:                                                Pick Up Time:                             Teacher’s

Name:                                 

Does your child have any medical problems?        Yes               No

*If yes, please explain:                                                                                                                

Does your child have any allergies? Yes               No

*If yes, please explain:                                                                                                                

*Please list all medications on the Health Record that accompanies this form.

Payment Plan:                  Yes               No

*If yes please provide us with the following information.

Credit Card Info:                                                                                  

Exp. Date:                                  CVV:                               

I                                                                             give LIC Kids permission to charge my credit card.

     (Print your name exactly as it appears on the credit card) 

Authorized Signature:                                                                                                                           

 LIC Kids Policies and Assumption of Risk Waiver

1. I certify that the enrollee has no condition that prohibits full participation in activities at LIC Kids.
2. Gymnastics or any activity that involves motions, rotation and height in a unique environment, carries with it a reasonable assumption of risk of physical injury.  In consideration for LIC Kids acceptance of the applicant and in consideration of the applicant’s opportunity to improve skills through the use of LIC Kids’ staff, equipment and facilities, those legally responsible for the named enrolling student realize the risk of injury involved and hereby agree to assume the responsibility of such for said student and further agree to save and hold harmless the said school, its employees and all other concerned and to indemnify them against loss, intending to be legally bound. 
3. I will provide all the known allergies of my child on this form.
4. I authorize LIC Kids to use any photographs taken of me or my child during classes, parties, and camps (etc.) for display.
5. In case of emergency, if I or my emergency contact cannot be reached, I authorize LIC Kids and its staff to contact and secure necessary medical attention for my child. 

LIC Kids Policies 

1. No food drinks or gum allowed in the gym. 
2. We will make every effort to accommodate your make-up needs however, because make-ups require an available space in class, we unfortunately cannot always guarantee one.  Please notify us in advance if you would like to participate in a make-up.  All make-up sessions must be taken before the end of the current semester.
3. Please do not bring cell phones or tablets into the gym.
4. Siblings who are not enrolled in the class may not participate.
5. LIC Kids will not be responsible for lost or stolen items.
6. All strollers should be stowed in the lobby.
7. LIC Kids is food-allergy aware and committed to providing safe environment for our members. Therefore we ask that you do not bring peanuts, nuts or food containing nut ingredients onto the premises. We are a NUT FREE facility.
8. I will notify LIC Kids of any changes in the medical condition of my child. By registering for programs at LIC Kids, I agree to follow all policies and procedures of the facility. I enroll understanding the risks and benefits of physical activity and state that all family members participating are in condition to play.
9. Personal checks are accepted. Please make checks payable to LIC Kids. Please note: there will be a $35 fee for returned checks. We will refund tuition for classes that have not occurred up until week 3 of the semester. After the 3rd week, we can issue a credit for future classes only. Discounts received are deducted from the refund. A $50 cancellation fee will apply.

Thank you for your cooperation, I understand and accept all enrollment conditions and policies stated above.

I have read and agree to the above terms:

                                                                   Date:                                                           

(Parent’s Signature)