Holiday Camp 2023 – Registering Now CLICK HERE FOR THE PARENT HANDBOOK –> FAC AfterSchool Parent Handbook Holiday Camp Registration Step 1 of 4 25% Camper InformationCamper's Name(Required) First Last Guest vs Member Rate Member Rate (34.99 per day per camper) Guest Rate (44.99 per day per camper) Select Days Attending(Required) Monday, December 18th Tuesday, December 19st Wednesday, December 20th Wednesday, December 27th Thursday, December 28th Friday, December 29th Tuesday, January 2nd Select AllCamper's Birth Date(Required) Month Day Year Camper's Age(Required)Camper's Grade(Required) Address(Required) Street Address Address Line 2 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 Parent/Guardian InformationParent/Guardian 1 Name(Required) First Last Parent/Guardian 1 Cell Phone(Required)Parent/Guardian 1 Work PhoneParent/Guardian 1 Home Address(Required) Street Address Address Line 2 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 Parent/Guardian 1 Email Address(Required) Parent/Guardian 1 Place of Employment Parent/Guardian 1 Work Hours Parent/Guardian 2 Name First Last Parent/Guardian 2 Cell PhoneParent/Guardian 2 Work PhoneParent/Guardian 2 Home Address Street Address Address Line 2 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 Parent/Guardian 2 Email Address Parent/Guardian 2 Place of Employment Parent/Guardian 2 Work Hours Emergency Contact InformationEmergency Contact Name First Last Relationship to Child Is This Person Authorized To Take The Child From FAC? Yes No Emergency Contact Cell PhoneEmergency Contact Work PhoneEmergency Contact Address Street Address Address Line 2 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 List All Other Adults Who Are Authorized To Take Child From FAC:Name First Last PhoneRelationship Name First Last PhoneRelationship Name First Last PhoneRelationship Medical InformationAllergies? (n/a if none)(Required) Physical or Emotional Concerns Your Child May Have:Special Food Needs? Prescribed Diet: Other Conditions or Comments?Please Select All of The Following Conditions/Illnesses That Your Child Has Had: Measels Chicken Pox Defective Heart Frequent Ear Infection Diabetes Mumps Whooping Cough Sun Sensitivity Frequent Throat Infection ADD/ADHD German Measels Positive TB Test Fainting Spells Frequent Colds Temper Tantrums Child's Physician or Emergency Treatment Facility: Phone NumberStreet Address Street Address Address Line 2 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 Hospital Emergency Room of Choice:(Required) 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.re Reset signature Signature locked. Reset to sign again Consent/AcknowledgmentI hereby give the Director of the Child Care Facility or his/her appointed representative permission to give my child Acetaminophen. I understand I will be notified if that medication has been administered Reset signature Signature locked. Reset to sign again I hereby give written permission for the use of suntan lotions/suncscreen for my child in permitable weather. In accordance with Minimun Licensing Requirements: DCCECE/Child Care Licensing Unit: 1100.1101.17 Reset signature Signature locked. Reset to sign again 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 in accordance with Minimum Licensing Requirements: DCCEDE/Child Care Licensing Unit: 200.201.4 Reset signature Signature locked. Reset to sign again This is to acknowledge that I have read and will comply with the rules as stated in the Kid's Fit Fun FACtory Parent Handbook (Attached at top)(Required) Reset signature Signature locked. Reset to sign again This is a statement of verification that I have been informed of the behavior guidance policy practiced. (Attached at top)(Required) Reset signature Signature locked. Reset to sign again I, the parent/guardian of this child, understand that I may ask for a conference with the caregiver(s) as needed. Reset signature Signature locked. Reset to sign again I verify that this form is complete in its entirety and that the parent handbook was given (attached at top) Reset signature Signature locked. Reset to sign again I, the Parent/Guardian, have read, understand, and agree with the Fayetteville Athletic Club Kid's Fit Fun FACtory Discipline Policies(Required) Reset signature Signature locked. Reset to sign again The discipline policy of the Fayetteville Athletic Club Kid's Fit Fun FACtory will be that anytime 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 FACtory uses a timeout situation to encourage good behavior. A child who has to take a time out will be taken out of class participation and must sit alone quietly under staff supervision for 1 minute for each year of age. After the second offense , another time out will be given. Following a third offense the child is sent home for the remainder of the day. Also, the parents and the child will have to schedule a conference with the director to discuss the problem. Continuous or more serious behavioral problems may result in termination from the Kid's Fit Fun FACtory program.I agree to abide by the Billing Policy that has been presented to me by the Fayetteville Athletic Club. I hereby acknowledge that all information provided by the undersigned is accurate and that I have read and understand the preceding prior to the signing and agree to all terms outlines above. I understand that the policy may change under the discretion of the billing office and/or director of the program. Reset signature Signature locked. Reset to sign again Kids Fit Fun FACtory programs will not admit a participant without Payment Agreement & Registration forms completed by bill payer and registration fees are paid. Each program may have separate and different fees and policies. Program costs are not affected when children cancel or miss days for which they are registered. No substitutions can be made for missed days. Drop in days are not available and children can only attend camp on days which they are registered and paid for. Payment must be made before child can attend camp. Non-payment by due dates will result is forfeit of student’s space in the program. Memberships, private lessons, personal training, and special programs are not included in fees but discounts may apply. FAC member discounts are only applicable if the child holds a “Junior Membership”. Any other discounts must be arranged with Director in writing prior to start of camp. FAC member discounts are void and additional charges will occur if membership is canceled during the time of camp attendance. The non-member rate will be charged to your account retroactively. Changes or cancellations in any registration must be made in writing to the director. This does not guarantee refund or credit of payments that have been made or cancellation any outstanding balances. A $25 fee is charged to any returned payments. Any payments made after a returned payment must be in cash or money order form. Failure to comply with payment will result in suspension of the participant. Non-payment after 60 days of billing date may be subject to collection agencies. Fayetteville Athletic Club accepts cash, money order, checks, Visa, Master Card, Discover, American Express. FAC will not accept any temporary checks. Monthly auto draft and FAC club account charge is not available for weekly programs such as camp, preschool or afterschool. For your convenience, a weekly draft may be set up on credit/debit card only. No child will be admitted into any FAC program if this form is not signed by a parent/legal guardian. By signing this form, you are releasing all claims for injury you or the participant might 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 as well FAC officers, agents, servants, and employees from such claims resulting from injury, damages,or loss sustained on account of participation in this FAC program or event. I understand that I am responsible for all personal insurance and the participant's family must cover any medical costs incurred. I also understand that every precaution is taken to protect the safety of each participant. I agree to emergency treatment by a physician or hospital in the event that I or the emergency contact listed cannot be reached.(Required) Reset signature Signature locked. Reset to sign again Payment InformationConsent(Required) I hereby authorize the Fayetteville Athletic Club to initiate debit entries and to initiate, if necessary, credit entries and adjustments for any debit entries in error to my (our) account indicated below and the financial institution named below, to credit and/or debit the same to such account. This authority is to remain in full force and effect for services utilized beginning August 14th, 2023 – May 31st, 2023 and until Fayetteville Athletic Club has received written notification from me (or either of us) of our 60 day cancellation. I understand that my account will continue to be drafted during the 60-day cancellation period.Credit Card Number(Required)Expiration Date(Required) Name on Card(Required) CVV(Required) Δ
