LAYERS Enrollment+Payment

Please complete this form to register your child for

the Layers program.

This form includes enrollment information, health & allergy details, authorized pick-up contacts,

behavior expectations, media release, and a required liability waiver.

All information is confidential.

Child’s Full Name

Date of Birth

Age

Parent/Guardian Name(s)

Mobile Phone

Home Address

Emergency Contact Name (not parent)

Emergency Contact Phone

Relationship to Child

Authorized Pick-Up

Please list all adults who are allowed to pick up your child. ID may be required

Does your child have any allergies?

Yes (please list the allergy/allergies)

Does your child carry any medication?

Yes (please specify)

Anything else we should know?

Media Release

This permission allows us to share photos or short videos from the program on our website and social media. No children’s names will be mentioned.

Yes, I give permission

No, I do not give permission

Other

Behavior & Community Guidelines

To keep our program safe and supportive, we ask that all children: treat peers and staff with respect, refrain from physical aggression or bullying, take care of materials and the space. If behavior becomes unsafe or disruptive, we may contact a parent to pick the child up early.

I have read and agree to the behavior expectations

Liability Waiver

By submitting this form, I understand and agree that participation in the program may involve minimal, ordinary risks (such as slips, falls, or minor injuries). I release and hold harmless the program, its instructors, staff, and the rented facility from any claims arising from accidental injury, except in cases of proven negligence. I authorize staff to call emergency medical services (911) if necessary. I am financially responsible for any medical treatment provided. I confirm that the information I have provided in this form is accurate.

I have read and agree to the Liability Waiver above

Parent Signature

Today’s date

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