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After-School Program / Supervised Play for Co-Working & Drop-off 

In Consideration of being allowed to enter the play area and/ or participate in any activities, party, play and/or After-school Supervised Play services for Co-working and Child Drop-off offered at Pikopye's Town, the undersigned, on his or her behalf, and on the behalf of the participant(s) identified below, acknowledges, appreciates, and agrees to the following conditions:

I Agree
I represent that I am a parent or legal guardian of the participant(s) named in this form, or I have obtained permission from a parent/legal guardian of the participant(s) named above to execute this agreement on his or her behalf.  

I Agree
The participant(s) in this form and I shall comply with all stated and customary terms, posted safety signs, rules and verbal instructions as conditions for participation in any activities, party, play and/or Supervised Play services offered at Pikopye's Town.

I Agree
I understand that since Pikopye's Town is not a licensed childcare, that Texas law dictates that their in house staff (not third party) can only supervise my child for up to four (4) hours a day, and a max of 12 hours per week with the Co-working option (not drop-off).

Policies & Procedures:

  • All reservations must be made no later than 24 hours before the session.  
  • All items must be brought from home must be labeled with the participant(s) name (blanket or water bottle). Toys from home are not permitted and Pikopye's Town is not responsible for any lost, damaged or stolen items brought from home.
  • Any food allergies and medications must be communicated in writing during the booking process to ensure safety of the child. Pikopye's Town is not a nut-free facility.  
  • Due to scheduling of Pikopye's Town staff when a spot is reserved, reservations may only be rescheduled once, and must be at 12 hours minimum prior to the scheduled session. Any rescheduling less than 12 hours prior is not permitted and all cancellations are non-refundable. A credit for another session may be issued for a different date if canceled 12 hours prior but there will strictly be no refund.
  • No credit or refund is due to all no-shows and all cancellations within 12 hours prior to session.

 

For Drop-offs Supervised Play (Parents Day / Night Out):

  • It is my responsibility to arrange the participant(s) to be picked up from Pikopye's Time within the 4 hour time limit. If the participant(s) is (are) not picked up on time, and attempts to contact me have failed, another Authorized Person will be contacted. All Authorized Person must provide a photo identification and listed on the form I filled out.
  • I understand that a $10 Late Pick-up Fee will be charged for every 15 minutes that participant is not picked up past the pick up time.  
  • In the event of an emergency, Pikopye's Town will attempt to contact me and if I cannot be reached, Pikopye's Town is authorized to contact one of my provided Emergency Contacts. In the event that no Emergeny Contact can be reached, Pikopye's Town is authorized to act for me, according to their best judgement in obtaining emergency medical treatment for any participant(s) name on the reverse.  
  • Pikopye's Town require all participant(s) is potty-trained. In the event that the participant(s) need to use the bathroom to potty, I give Pikopye's Town permission to accompany them if necessary to ensure child's safety. If I am not comfortable with this, I will let any of the staff know in writing upon drop-off.
  • I hereby testify that my child is toilet trained and that they can use the bathroom with minimal accompaniment of a staff member.



I am aware that there are inherent risks associated with participation in Pikopye's Town Supervised Play programs, parties, and drop-off services, and I, on behalf of myself, and the participant(s) named on the form, knowingly and freely assume all such risk, both known and unknown, including those that may arise out of the negligence of other participants; and, I, ofr myself adn teh particpant(s) named, and our respective heirs, assigns, administrators, personal representatives, and next of kin, agree to indemnify and hold harmless, Pikopye's Town (Dalemi Group LLC), the management, their affiliates, officers, members, agents, employees, other participants, and sponsoring agencies from and agains any and all claims, injuries, liabilities, or damages arising out of or related to our particpation in any and all Pikopye's Town programs, activities, parties and use of the play areas.

 

I Agree
I certify that I have read, understand and agree to all Pikopye's Town Policies & Procedures written above.

 

 


First Child's Name

First Name*

Middle Name

Last Name*
First Child's Date of Birth*
First Child's Parents/Guardian Information

Parent First & Last Name *
Relationship to Child*
First Child's Signature*
Second Child's Name

First Name*

Middle Name

Last Name*
Second Child's Date of Birth*
Second Child's Parents/Guardian Information

Parent First & Last Name *
Relationship to Child*
Third Child's Name

First Name*

Middle Name

Last Name*
Third Child's Date of Birth*
Third Child's Parents/Guardian Information

Parent First & Last Name *
Relationship to Child*
Fourth Child's Name

First Name*

Middle Name

Last Name*
Fourth Child's Date of Birth*
Fourth Child's Parents/Guardian Information

Parent First & Last Name *
Relationship to Child*
Fifth Child's Name

First Name*

Middle Name

Last Name*
Fifth Child's Date of Birth*
Fifth Child's Parents/Guardian Information

Parent First & Last Name *
Relationship to Child*
Sixth Child's Name

First Name*

Middle Name

Last Name*
Sixth Child's Date of Birth*
Sixth Child's Parents/Guardian Information

Parent First & Last Name *
Relationship to Child*
Seventh Child's Name

First Name*

Middle Name

Last Name*
Seventh Child's Date of Birth*
Seventh Child's Parents/Guardian Information

Parent First & Last Name *
Relationship to Child*
Eighth Child's Name

First Name*

Middle Name

Last Name*
Eighth Child's Date of Birth*
Eighth Child's Parents/Guardian Information

Parent First & Last Name *
Relationship to Child*
Ninth Child's Name

First Name*

Middle Name

Last Name*
Ninth Child's Date of Birth*
Ninth Child's Parents/Guardian Information

Parent First & Last Name *
Relationship to Child*
Tenth Child's Name

First Name*

Middle Name

Last Name*
Tenth Child's Date of Birth*
Tenth Child's Parents/Guardian Information

Parent First & Last Name *
Relationship to Child*
Child's 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*
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
Parent or Guardian's Driver's License / ID Card

Driver's License / ID Card Number*

Issuing State*
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.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Relationship*
Parent or Guardian's Date of Birth*
Parent or Guardian's Parents/Guardian Information

Parent First & Last Name *
Relationship to Child*
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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