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11 Clearbrook Road Elmsford, NY 10523  (914) 347-5291  www.theplayplace.net

2019 Sports Registration Form

Cancellation, Refund and Make up Policy
$50 deposit due with reservation and balance due before the 1st day of the season. Refunds are at the descreation of the porgram director and General Manager. Program sessions cancelled will be left on account for future use.  Make ups requests must be made in advance in writing to Program Director. No refunds will be issued after session begins. We allow 1 make up per session. (must me schedule in advance with directors apporoval)

2019 Sports Waiver of Liability

Indicated in the space below are any health problems or conditions of which The Play Place should be aware (such as heart, back, medical, allergy, muscular, diabetes, epilepsy, chemical or neurological condition, special medication, knee/kidney/shoulder problems, etc.). I understand that risk of injury is inherent in any physical activity and I, on behalf of myself and my child, knowingly and voluntarily accept that risk. I, the undersigned, for myself, my heirs, administrators, and executors, hereby waive and release The Play Place and the staff from all claims or damages of any kind arising out of my child’s participation in the sports program of The Play Place.  I further certify that the student is in proper physical condition to participate in the sports program and that he/she has been examined by a licensed physician and found to be in proper physical condition to participate in said program. I, the undersigned, do hereby authorize the Play Place and its designated agents (being teachers or administrators employed by The Play Place) to obtain medical treatment for my said child in emergency situations where I cannot be reached in time to authorize the treating physician to provide such emergency medical services. I understand that I am responsible for any medical expenses and that the absence of health insurance does not make The Play Place responsible for payment of medical expenses. This authority includes the power to authorize all treatment deemed necessary under the circumstances by a licensed physician. This power is in essence a power of attorney and shall remain in effect for one year from the date signed below.

Today's Date: December 10, 2019

First Student Name

First Name*

Last Name*

Phone*
First Student Date of Birth*
I certify that I am 18 years of age or older
First Student Information
Program*
Season:*

Session Level

Day

Time

Age

Mom's Name

Cell Phone

Dad's Name

Cell Phone

Medical Information & Allergies:
Photo/Video Release: I hereby grant permission to The Play Place LLC to use photographs and/or videos of my child(ren) for use in promotional and marketing materials, online and in publications related to The Play Place LLC.*
No
Yes
First Student Signature*
Second Student Name

First Name*

Last Name*

Phone*
Second Student Date of Birth*
Second Student Information
Program*
Season:*

Session Level

Day

Time

Age

Mom's Name

Cell Phone

Dad's Name

Cell Phone

Medical Information & Allergies:
Photo/Video Release: I hereby grant permission to The Play Place LLC to use photographs and/or videos of my child(ren) for use in promotional and marketing materials, online and in publications related to The Play Place LLC.*
No
Yes
Third Student Name

First Name*

Last Name*

Phone*
Third Student Date of Birth*
Third Student Information
Program*
Season:*

Session Level

Day

Time

Age

Mom's Name

Cell Phone

Dad's Name

Cell Phone

Medical Information & Allergies:
Photo/Video Release: I hereby grant permission to The Play Place LLC to use photographs and/or videos of my child(ren) for use in promotional and marketing materials, online and in publications related to The Play Place LLC.*
No
Yes
Fourth Student Name

First Name*

Last Name*

Phone*
Fourth Student Date of Birth*
Fourth Student Information
Program*
Season:*

Session Level

Day

Time

Age

Mom's Name

Cell Phone

Dad's Name

Cell Phone

Medical Information & Allergies:
Photo/Video Release: I hereby grant permission to The Play Place LLC to use photographs and/or videos of my child(ren) for use in promotional and marketing materials, online and in publications related to The Play Place LLC.*
No
Yes
Fifth Student Name

First Name*

Last Name*

Phone*
Fifth Student Date of Birth*
Fifth Student Information
Program*
Season:*

Session Level

Day

Time

Age

Mom's Name

Cell Phone

Dad's Name

Cell Phone

Medical Information & Allergies:
Photo/Video Release: I hereby grant permission to The Play Place LLC to use photographs and/or videos of my child(ren) for use in promotional and marketing materials, online and in publications related to The Play Place LLC.*
No
Yes
Sixth Student Name

First Name*

Last Name*

Phone*
Sixth Student Date of Birth*
Sixth Student Information
Program*
Season:*

Session Level

Day

Time

Age

Mom's Name

Cell Phone

Dad's Name

Cell Phone

Medical Information & Allergies:
Photo/Video Release: I hereby grant permission to The Play Place LLC to use photographs and/or videos of my child(ren) for use in promotional and marketing materials, online and in publications related to The Play Place LLC.*
No
Yes
Seventh Student Name

First Name*

Last Name*

Phone*
Seventh Student Date of Birth*
Seventh Student Information
Program*
Season:*

Session Level

Day

Time

Age

Mom's Name

Cell Phone

Dad's Name

Cell Phone

Medical Information & Allergies:
Photo/Video Release: I hereby grant permission to The Play Place LLC to use photographs and/or videos of my child(ren) for use in promotional and marketing materials, online and in publications related to The Play Place LLC.*
No
Yes
Eighth Student Name

First Name*

Last Name*

Phone*
Eighth Student Date of Birth*
Eighth Student Information
Program*
Season:*

Session Level

Day

Time

Age

Mom's Name

Cell Phone

Dad's Name

Cell Phone

Medical Information & Allergies:
Photo/Video Release: I hereby grant permission to The Play Place LLC to use photographs and/or videos of my child(ren) for use in promotional and marketing materials, online and in publications related to The Play Place LLC.*
No
Yes
Ninth Student Name

First Name*

Last Name*

Phone*
Ninth Student Date of Birth*
Ninth Student Information
Program*
Season:*

Session Level

Day

Time

Age

Mom's Name

Cell Phone

Dad's Name

Cell Phone

Medical Information & Allergies:
Photo/Video Release: I hereby grant permission to The Play Place LLC to use photographs and/or videos of my child(ren) for use in promotional and marketing materials, online and in publications related to The Play Place LLC.*
No
Yes
Tenth Student Name

First Name*

Last Name*

Phone*
Tenth Student Date of Birth*
Tenth Student Information
Program*
Season:*

Session Level

Day

Time

Age

Mom's Name

Cell Phone

Dad's Name

Cell Phone

Medical Information & Allergies:
Photo/Video Release: I hereby grant permission to The Play Place LLC to use photographs and/or videos of my child(ren) for use in promotional and marketing materials, online and in publications related to The Play Place LLC.*
No
Yes
Student Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Information
Program*
Season:*

Session Level

Day

Time

Age

Mom's Name

Cell Phone

Dad's Name

Cell Phone

Medical Information & Allergies:
Photo/Video Release: I hereby grant permission to The Play Place LLC to use photographs and/or videos of my child(ren) for use in promotional and marketing materials, online and in publications related to The Play Place LLC.*
No
Yes
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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