Active After School 2025-2026 Registration

Active Kids After School 2025-2026 Registration

"*" indicates required fields

Step 1 of 10 – Child Information

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Child Basic Information

Child's Name*

First Last

Birth Date*

MM slash DD slash YYYY

Child's Age*

Grade (25-26 School Year)*

School Attending?*

Child Medical Information

Allergies? ("na" if none)*

Please list any pertinent information that may help us properly care for your child in our program (Including Relevant Medical Information, Medicine Currently Taking, Emotional Needs, Social Needs, etc.)

Other Conditions or Comments?

How Many Additional Kids Would You Like to Register?

Second Child Basic Information

Child's Name*

First Last

Birth Date*

MM slash DD slash YYYY

Child's Age*

Please enter a number from 5 to 12.

Grade (25-26 School Year)*

School Attending?*

Second Child Medical Information

Allergies? (na if none)*

Other Conditions or Comments?

Third Child Basic Information

Child's Name*

First Last

Birth Date*

MM slash DD slash YYYY

Child's Age*

Please enter a number from 5 to 12.

Grade (25-26 School Year)*

School Attending?*

Third Child Medical Information

Allergies? (na if none)*

Other Conditions or Comments?

Fourth Child Basic Information

Child's Name*

First Last

Birth Date*

MM slash DD slash YYYY

Child's Age*

Please enter a number from 5 to 12.

Grade (25-26 School Year)*

School Attending?*

Fourth Child Medical Information

Allergies? (na if none)*

Other Conditions or Comments?

Primary Parent/Guardian Information

Primary Parent/ Caregiver Name*

First Last

Relationship to child:*

Primary Parent/ Guardian Cell Phone*

Home Address*

Street Address City State ZIP Code

Primary Caregiver Email*

Primary Parent/Caregiver's Place of Employment*

Work Phone*

Work Hours?

Secondary Parent/Caregiver Information

Secondary Parent/Caregiver Name

First Last

Relationship to child:

Secondary Caregiver Cell Phone

Home Address

Street Address Address Line 2 State ZIP Code

Secondary Caregiver Email

Secondary Parent/Caregiver's Place of Employment*

Work Phone*

Work Hours?

Emergency Contact Information

Emergency Contact Name*

First Last

Phone Number*

Relationship to Child*

Is The Emergency Contact Authorized To Take Your Child From FAC?*

In The Event Of An Emergency

Hospital Emergency Room of Choice:*

Phone Number of Emergency Room Choice*

List any other adults who are authorized to take the child from the center:

Name

First Last

Cell Phone

Relationship

Name

First Last

Cell Phone

Relationship

Name

First Last

Cell Phone

Relationship

Policies & Waivers

Transportation Consent*

I understand that my child will be transported by the FAC buses and/or vans. I grant the Fayetteville Athletic Club team permission to transport my child to/from their school.

I have reviewed the above and agree to the above statement.

Photo/Video Authorization

We will be taking pictures throughout the year to capture the action and adventure of our Kids FACtory programs. I hereby grant permission to Fayetteville Athletic Club to use photographs and/or video of my child(ren) taken during FAC programs, in publications, news releases, online, and in other communications related to the Kid FACtory programs.

I have reviewed the above photo/video authorization and grant permission (Do not check this box if you do not grant permission)

Acetaminophen Authorization

I give, or do not give the Director of the Kid’s FACtory or his/her appointed representative, permission to give my child Acetaminophen. I understand that I will be notified if that medication has been administered and in other communications related to the Kid FACtory programs.

I have reviewed the above authorization and grant permission (Do not check this box if you do not grant permission)

FAC Waiver Release Statement*

I agree to the Fayetteville Athletic Club’s Waiver release statement. I understand that I am releasing all claims for injury, I or my child may sustain through any of our programs. I agree to assume full risk and to waive, relinquish, and release all claims I and/or the participant may have against, indemnify, hold harmless and defend the Fayetteville Athletic Club. This release includes FAC officers, agents, servants, and employees from such claims resulting from injury, damages, or loss sustained while participating in the FAC program or event. I understand that I am responsible for all personal insurance and understand that I must cover any medical costs incurred for my family participating in this FAC program. I also understand that every precaution is taken to protect the safety of each participant.

I’ve reviewed the above statement and agree

Medical Emergency Consent*

I, (mother/father/guardian), do hereby give my consent to the Director of the Child Care facility, or his/her representative, for said child to receive medical or surgical aid as may be deemed necessary and expedient by a duly licensed or recognized physician or surgeon in case of emergency when parent/guardian can not be reached. Consent is also given for the Director or his/her duly appointed representative to transport said child for emergency medical treatment, if the parents cannot be reached. Please sign below.

I’ve reviewed the above statement and agree

FAC After School Billing Policy*

The Registration fee and first week of After School fees must be paid to register your child(ren) for the FAC After School Program. The balance will be billed the Friday prior to each week of After School. This balance must be paid by a credit card or bank account on file with FAC. Payments must be received for your camper to attend After School. Non-payment by the required due dates will result in relinquishing the camper’s space in the program. FAC Junior Membership are required for each child to receive the Member discount for our After School program. Changes or cancellation requests must be received a minimum of 2 weeks prior to the start of After School and must be made in writing to the Director. FAC member discounts will be voided and additional charges will occur if the FAC Junior membership is canceled at any time during the program duration. A $25 returned payment fee will be applied to any returned payments. Fayetteville Athletic Club accepts, Visa, Master Card, Discover, American Express, bank drafts and checks. I agree to abide by the Billing policy that has been presented.

I’ve reviewed the billing policy above and agree

DHS Licensing Acknowledgments*

This is a statement of verification that I have been informed that child care licensing/ child maltreatment investigators and/or law enforcement may possibly interview my child for the purpose of determining licensing compliance or for investigative purposes. This is accordance with Minimum Licensing Requirements: DCCEDE/ Child Care Licensing Unit: 200.201.4