Code Breakers Camp Registration "*" indicates required fields Step 1 of 10 – Child Information 10% Child Basic InformationChild's Name* First Last Birth Date* MM slash DD slash YYYY Child's Age*Grade (25-26 School Year)*Select Days Attending*Prices: FAC Jr Members – $40 / day / camper; FAC Guests – $48 / day / camper Friday, October 10, 2025 Monday, October 13, 2025 Select AllChild Medical InformationAllergies? ("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?0123 Second Child Basic InformationChild'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)*Select Days Attending* Friday, October 10, 2025 Monday, October 13, 2025 Select AllSecond Child Medical InformationAllergies? (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? Third Child Basic InformationChild'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)*Select Days Attending* Friday, October 10, 2025 Monday, October 13, 2025 Select AllThird Child Medical InformationAllergies? (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? Fourth Child Basic InformationChild'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)*Select Days Attending* Friday, October 10, 2025 Monday, October 13, 2025 Select AllFourth Child Medical InformationAllergies? (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? Primary Parent/Guardian InformationPrimary Parent/ Caregiver Name* First Last Relationship to child:*Primary Parent/ Guardian Cell Phone*Home Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary Caregiver Email* Primary Parent/Caregiver's Place of Employment*Work Phone*Work Hours? Secondary Parent/Caregiver InformationSecondary Parent/Caregiver Name First Last Relationship to child:Secondary Caregiver Cell PhoneHome Address Street Address Address Line 2 AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Secondary Caregiver Email Secondary Parent/Caregiver's Place of Employment*Work Phone*Work Hours? Emergency Contact InformationEmergency Contact Name* First Last Phone Number*Relationship to Child*Is The Emergency Contact Authorized To Take Your Child From FAC?*YesNoIn The Event Of An EmergencyHospital 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 PhoneRelationshipName First Last Cell PhoneRelationshipName First Last Cell PhoneRelationship Policies & WaiversPhoto/Video AuthorizationWe 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 AuthorizationI 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. By signing this form, 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 agreeMedical 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 agreeFAC Camp Billing Policy*The payment for the camp must be paid by the Friday before the day of the camp in order to register your child(ren) for the FAC School Day Out Camp. The balance will be billed the Friday prior to the event. 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 the camp. Non-payment by the required due dates will result in relinquishing the camper’s space in the camp. FAC Junior Membership is required for each child to receive the Member discount for the camp. Changes or cancellation requests must be received a minimum of 5 days prior to the day of the camp 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 agreeDHS 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 I’ve reviewed the above and agreeKids FACtory Parent Handbook Acknowledgments*This is to acknowledge that I have received and will comply with the rules as stated in the Kids Fun FACtory Parent Handbook. I’ve reviewed the above and agreeKids FACtory Behavior Guidance Policy Acknowledgments*I have been informed of the behavior guidance policy practiced listed in the Kids FACtory Parent Handbook. I’ve reviewed the above and agreeAcknowledgments*I understand that I may ask for a conference with the caregiver(s) as needed. I’ve reviewed the above and agreeDiscipline Policy*The discipline policy of the Fayetteville Athletic Club, Kids Fit Fun FACtory will be that any time a child’s behavior jeopardizes the safety of him/herself, others or is acting in a disruptive manner, the child will be removed from the class or program. The Kids FACtory uses “timeout” to encourage good behavior. A child who has been given a “timeout” will be taken out of the group/class participation and must sit alone quietly under staff supervision for 1 minute for each year of age. After the 2nd offense, another timeout will be given. Following a 3rd offense, the child will be sent home for the remainder of the day. The parents and child will need to schedule a conference with the Director to discuss the issue. Continuous or more serious behavior issues may result in suspension/ pending termination from the Kid’s Fit Fun FACtory program. I understand and agree to comply with the Discipline Policy. I’ve reviewed the above and agree Billing InformationCredit Card Number*Credit Card Type*VISAMastercardDiscoverAmerican ExpressExpiration Date*CVV*Name on Credit Card* First Last
