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STAY-N-PLAY

INTAKE FORM

Waiver and Release of Liability 

In consideration of gaining membership or being allowed to participate in the activities and program so UNC Wellness Centers and to use its facilities, I do give my consent to place the care of my child or legal dependent in the care of the childcare staff during my workout time in the facility.

I do understand that I must utilize UNC Wellness Centers’ childcare services with scheduled agreement between the facility and myself, understanding that space must be reserved for my child each time I wish to use Stay-N-Play. I know that I am not permitted to leave the premises of UNC Wellness Centers for any reason while my child is in Stay-N-Play.

I will not bring my child(ren) into Stay-N-Play with knowledge of any illnesses, open wounds, pink eye, constant cough or runny nose for more than 24 hours, loose stools, and rashes/skin irritations. If my child displays any of the above, while in the care of The UNC Wellness Centers staff, I understand that I will be notified immediately during my workout and am expected to remove my child from Stay-N-Play. Under no circumstances will the staff administer medication to my child.

In consideration of placing my child(ren) in Stay-N-Play with UNC Wellness Centers, I agree to assume all risks of injury and will hold harmless from any and all liability, causes of actions, claims and demands of every kind and nature whatsoever which I now have, or which may arise of or in connection with any participation in activities arranged by The UNC Wellness Center staff and its employees. These terms will serve as a release and assumption of risk for my heirs, executors and administrators for all members of my family including any minors. 


Stay-N-Play Policies 

  • All children must be members to be checked into Stay-N-Play. Participation in Stay-N-Play is included for children who are members.
  • The parent or guardian must remain in the facility while the child is checked into Stay-N-Play.
  • 1.5 hours is the maximum duration of time that a child may stay per reservation.
  • The Stay-N-Play is available to children ages 2-12 years old.
  • Child must be signed in and out by parent or guardian. Only adults listed on the authorized pick-up form will be allowed to sign out child. Photo identification will be verified at the time of sign out. The parent or guardian who signs the child in should be the one to sign the child out unless notified at sign in.
  • Reservations are required. Reservations may be made up to one week in advance beginning at 12:00pm. Reservations will be forfeited if 10 minutes past start time. 
  • Reservation should be made under the child’s name. Each child needs a separate reservation space. 
  • Your appointment is reserved for you. In order to keep our schedules working for all of our members, we need at least a 2-hour notice for all cancellations and rescheduling.
  • If no-shows or cancellations occur with less than a 2-hour notice the following measures will be taken:
  • 1st Occurrence: Warning
  • 2nd Occurrence: Final Warning
  • 3rd Occurrence: Automatic $15.00 charge to your account.
  • If a parent or guardian is more than 5 minutes late picking up, the following measures will be taken:
  • 1st Occurrence: Warning
  • 2nd Occurrence: Final Warning
  • 3rd Occurrence: 2-week suspension from Stay-N-Play
  • Medication will not be administered by Stay-N-Play attendant. If a child has a life-threatening allergy, an epi-pen may be stored in the Stay-N-Play while the child is checked in.
  • Due to possible food allergy and choking, no food is allowed. Labeled water bottles are permitted.
  • For the health and safety of all children in Stay-N-Play, parents and guardians are responsible for any and all diapering and potty needs.
  • For the safety and well-being of all children, no sick children are allowed in Stay-N-Play. If a child shows any signs of illness, the attendant on duty will immediately notify the parent to take the child home.
  • Upon arrival in Stay-N-Play, both staff and children must wash their hands with soap and water or hand sanitizer.
  • All children must wear shoes in Stay-N-Play at all times.
  • For the protection and safety of all children, no photographs or videos can be taken in the Stay-N-Play.
  • Stay-N-Play is not responsible for lost, stolen, or damaged items.
  • Any personal property brought into Stay-N-Play must be labeled with child's full name. Individual's toys should be left at home. Strollers may not be stored in Stay-N-Play.
  • Personal electronic devices are not permitted in Stay-N-Play.
  • For safety and security, we limit the time parents are in the Stay-N-Play to 5 minutes.
  • When necessary, redirection and time-outs will be used to address behavioral occurrences.
  • If inappropriate behavior disrupts Stay-N-Play or is unacceptable to staff or participants, the following measures will be taken:
  • 1st Occurrence: Warning
  • 2nd Occurrence: Final Warning
  • 3rd Occurrence: 2-week suspension from Stay-N-Play

Today's Date: July 16, 2025

First Participant's Name
First Name*
Middle Name
Last Name*
First Participant's Date of Birth*
Date of Birth
First Participant's Information
Allergies: *
Additional Information:
First Participant's Signature*
Second Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Second Participant's Information
Allergies: *
Additional Information:
Third Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Third Participant's Information
Allergies: *
Additional Information:
Fourth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Fourth Participant's Information
Allergies: *
Additional Information:
Fifth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Fifth Participant's Information
Allergies: *
Additional Information:
Sixth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Sixth Participant's Information
Allergies: *
Additional Information:
Seventh Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Seventh Participant's Information
Allergies: *
Additional Information:
Eighth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Eighth Participant's Information
Allergies: *
Additional Information:
Ninth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Ninth Participant's Information
Allergies: *
Additional Information:
Tenth Participant's Name
First Name*
Middle Name
Last Name*
Participant's Date of Birth*
Date of Birth
Tenth Participant's Information
Allergies: *
Additional Information:
Parent or Guardian's Email Address
Email*
Confirm Email*
Authorized Pick-Up: Please list the individuals who may pick up your child. Child will not be allowed to leave with any other persons without written permission from parent/guardian. (picture ID required)
Authorized Pick-up 1:
Name:
Relationship
Phone Number:
Authorized Pick-up 2:
Name:
Relationship:
Phone Number:
Authorized Pick-up 3:
Name:
Relationship:
Phone Number:

I, Parent(s) or Legal Guardian(s),  have read and understand all terms to the agreement and conditions 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*
Phone*
Parent or Guardian's Date of Birth*
Date of Birth
Parent or Guardian's Information
Allergies: *
Additional Information:
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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