Kids Night Out at The Learning Center

Section #1 ~ Child's Information

Name of Child Enrolled *

First

Last

DATE OF BIRTH *

Name of School *

"ANY" SPECIAL NEEDS STAFF NEED TO BE AWARE OF? (N/A) IF NOT APPLICABLE *

Any allergies? N/A if not applicable *

Section #2 ~ Sibling's Info

Insert The Name(s) of Sibling(s) "N/A" if Not Applicable *

Sibling(s) Date of Birth *

Sibling(s) Allergies or Special Needs? N/A if not applicable *

Insert the name of the Last Symbolic Art Program Enrolled *

How Did You Hear About Symbolic Art Learning Center? *

Kids' Night Out Dates *

Oct 3rd Oct 17th

Kids' Night Out Dates *

Nov 7th Nov 21st

Section #3
Enrolling Parent/Guardian Info

Parent or Guardian's Name *

First

Last

Parent or Guardian's Email *

Alternate Email *

Alt Phone# *

Insert The Name & Phone Number To Receive Text Messages *

Insert Home Address *

Line 1

Line 2

City

State

Zip Code

Country

Section #4
Emergency Contact Info

1st Emergency Contact's Name N/A if Not Applicable *

First

Last

Phone# N/A if Not Applicable *

2nd Emergency Contact's Name N/A if not applicable *

First

Last

Phone# N/A if Not Applicable *

Insert Name(s) of anyone other than parent, guardian or emergency contact who may pick up Child(ren) *

Fee Disclosure*

An 'annual' registration fee: $25 is required for each new participant not currently enrolled in other Symbolic Art programs; Symbolic Art Learning Center rates: *$27 1st Child & $13 Siblings *Enrollment fees are non-refundable in the case a participant is absent from the program. Payments may be made in cash, money order or credit card. Payments will only be accepted from adults listed on this form. A $10 late fee will be assessed for each :15 minutes past 6:00 p.m. (e.g. 6:05 pm / pick up = $10)

Sign-In & Sign-Out

To protect the safety of our children I understand each child must:

Not enter the learning facility with a cough that cannot be attributed to another health condition
Not enter the learning facility with a condition of shortness of breath that cannot be attributed to another health condition
Not enter the learning facility with any two of the following symptoms: Fever (100.4 F or higher), chills, repeated shaking with chills, muscle pain, headache, sore throat or new loss of taste or smell
Not enter the learning facility if the child had come into close contact (within 6 feet) with someone who has a laboratory confirmed COVID-19 diagnosis in the past 14 days
Participants will be escorted to and from the learning facility by Symbolic Art Staff. Parents/Guardians/Visitors will not be permitted inside the learning facility.
The only person(s) authorized to pick up the child(ren) are those listed on this form; photo ID must be shown.

Waiver of Claim*

For ourselves, and/or on behalf of our child named above, our heirs, executors, and administrators, we hereby do expressly and forever waive and hold harmless Symbolic Art Central, Inc dba Symbolic Art and their respective officers, employees, agents or representatives from any and all liability for personal injury or damages, sustained, incurred, arising from and/or connected with travel to, return from any and all classes, activities, tournaments and/or special events, and all activities related to, or in connection with said activity by ourselves or by our child. *Symbolic Art is a community based organization focused on making sports, recreation and artistic expression fun for youth ages 5-12.During programs or events sponsored Symbolic Art staff may take photos of participants that may be used in professionally designed publications, Symbolic Art websites, social media platforms and other promotional materials.

Kids' Night Out

Kids' Night Out - Siblings

The Symbolic Art Learning Center, 2020
Please note that all fields followed by an asterisk must be filled in

Section #1 ~ Child's Information

Section #2 ~ Sibling's Info

Section #3
Enrolling Parent/Guardian Info

Section #4
Emergency Contact Info

Fee Disclosure*

Sign-In & Sign-Out

Waiver of Claim*

Parent Letter*

Please Type Your Name to Acknowledge An Acceptance of Symbolic Art Terms & Conditions

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Kids' Night Out

Kids' Night Out - Siblings

The Symbolic Art Learning Center, 2020Please note that all fields followed by an asterisk must be filled in

Section #1 ~ Child's Information

Section #2 ~ Sibling's Info

Section #3Enrolling Parent/Guardian Info

Section #4Emergency Contact Info

Fee Disclosure*

Sign-In & Sign-Out

Waiver of Claim*

Parent Letter*

Please Type Your Name to Acknowledge An Acceptance of Symbolic Art Terms & Conditions

Follow us!

The Symbolic Art Learning Center, 2020
Please note that all fields followed by an asterisk must be filled in

Section #3
Enrolling Parent/Guardian Info

Section #4
Emergency Contact Info