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                      Sumner Skate Zone
                     After School Program
                                            Application

LAST NAME (child):___________________________________________________

FIRST NAME(child):___________________________________________________

ADDRESS:___________________________________________________________

CITY:_________________________STATE:_______________ZIP:_____________

HOME PHONE:__________________________AGE:_____GRADE:___________

PARENTS E-Mail:____________________________________________________

SCHOOL ATTENDING:_______________________________________________

                                       FEES

 

Registration $40 or $60 Family                                                     Weekly Fee:                     (official use only)                                                                      Five Days: $65.00 Date paid:________________                                                 Three Days: $55.00  Payment Method:__________                                                  Two Days: $40.00 Initial:___________________

 

                               Days Attending

Three Days:_____________________________

Two Days: ______________________________

I hereby enroll in Sumner Skate Zone’s AfterSchool Program. I agree to pay the above tuition along with a
$40 registrationfee. I understand that no refund what so ever will be made to me if I fail to appear. I understand
the After School Program fees are due the Friday before the week my child(ren) attend or there will be a $20 late
fee for any payments made after Monday of the week of attendance.

Date: __________________                                                           Parent’s Signature: ____________________________                         

STUDENT NAME:______________________________________________________

I am in good health and know of no physical or mental defects that would endangermy own well
being or that of other students. I understand that there arecertain physical risk associated with engaging
in roller skating and relinquish all rights to claim or recover damages for personal injury in connection
with my activities at Sumner Skate Zone. These activities include those activities performed at the
facility, off the facility, and in transport to and from the facility. Permission is hereby given for my
child(ren) to participate in all of the facilities activities, including but not limited to skating, games and
playtime. This release of legal rights is not only binding upon me, but upon my survivors and representatives
as well. This release operates in favor of Sumner Skate Zone and its employees. I knowingly and
voluntarily give up my legal rights against all of the persons and entities.

I/we understand that attendance at Sumner Skate Zone After School Program is a privilege and
we agree to abide by the policies and rules established by the facility and as stated on the rules
sheet. We agree to cooperate with the staff in a supportive manner.

_________________________                                              ________________________
  Print name of parent or guardian                                                                                             Date
 

_____________________________________
                          Signature

                           SumnerSkate Zone
                        After School Program

Student: __________________________________________

Address:__________________________________________

Parent/guardian: ___________________________________

Home phone: _____________Cell phone:________________

Alternate phone: ____________________________________

Employment: __________________Work phone: ____________

Student’s physician: _________________Phone:_____________

Medications: ________________________________________

For treatment of: _____________________________________

List any other health problem or physical limitations: __________

__________________________________________________

List all Allergies:____________________________________

EMERGENTCY CONTACTS
Please list those individuals you hereby allow to pick-up your child(ren) if the parent/guardian
can not be reached. Your child will not be released to anyone who is not on the list.

Name:_________________________relationship:_______________phone:___________

Name:_________________________relationship:_______________phone:___________

Name:_________________________relationship:_______________phone:___________

Name:_________________________relationship:_______________phone:___________

I hereby give permission for the owners and employees of Sumner Skate Zone to obtain
treatment for my child ___________________________ in the event of an emergency.

Parent/guardian signature:_________________________ Date: ___________________

I, _______________, give ____________________, permission to
                  (Parent’s name)                                                          (School’s Name)

let my child/children____________________________, go on

transportation provided by SumnerSkate Zone After School program.

_____________________            __________    _______________
           (Parents Signature)                                                              (Date)                                         (Phone number)

1. Sumner Skate Zone’s After School Program will operate Monday
   thru Friday from the time we pick them up from school until 6:00pm.
2. All students must be picked up between 6:00 and 6:15.
3. A $5.00 late fee will be charged per child picked up after 6:16p.m
   with an additional $5.00 per every 15 minutes there after.
4. There will be a $20.00 charge on all returned checks.
5. Parents must sign out their child(ren) when they are picked up.
6. Only those persons listed on the Emergency contact list will be
   allowed to pick up the child(ren) unless the parent or Legal guardian
   make a written or verbal request, in person or to the program director.
   That person must present a valid I.D before we will dismiss the child
   to him/her.
7. It is the parent’s/legal guardian’s responsibility to notify Sumner
   Skate Zone if the child(ren) does not attend school that day or is
   going on vacation. This is extremely important so we know they
   were not in school and therefore will not be attending the program
   and do not need to be picked up.
8. During homework time ALL students must do work. If they are
   finished their homework they can read.
9. A two week notice must be given in writing if you plan on removing
   your child for the program.
10. Sumner Skate Zone is not responsiblefor any personal items left
    anywhere on the premises.

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