CHB Sports, Inc. - Berks County's Fitness Leaders!

Colonial Sports
Afterschool Program

ONLINE REGISTRATION

2010 - 2011

Section1: General Information

After School Program: *		School: *		Dismissal Time: *
(select days if Part Time:) M T W Th F		School District: *

CHILD
Name: *	Age:	Birth date: (01/01/01) Sex:

Address:	Home Phone: * (Example: 000-000-0000)
City: Zip Code:
Child's Doctor:
Doctor's Address:	Doctor's Phone:
Health Insurance Coverage:	Insurance Policy Number:
MOTHER	FATHER
Name: *	Name: *
Address:	Address:
Home Phone: (Example: 000-000-0000)	Home Phone: (Example: 000-000-0000)
Cell Phone: (Example: 000-000-0000)	Cell Phone: (Example: 000-000-0000)
Email: *	Email: *
*If you have only one email address, please enter it in both email fields.
Business Name:	Business Name:
Business Address:	Business Address:
Business Phone: (Example: 000-000-0000)	Business Phone: (Example: 000-000-0000)
Estimated "arrival" time: (optional)	Estimated "departure" time: (optional)

I agree to pay a fee of $ ______________ per ______________ for services indicated above.

Payments must be paid in full, based on the above fee schedules, on the first day of the week/month for which service is rendered.
Payments may be paid in cash, check, money order, Visa or Master Card.
Late fees will be charged for any payment not received by its 'due date'.
No refunds are given or deductions made to payments for any days that a child is absent.

I agree to pay an "Initial Registration" fee of $35.00 to be paid at the time of enrollment.

I understand that my child will only be released to the individuals listed below. If any exceptions are made, it may only be made in writing and signed by me, clearly identifying who may pick up my child. This will be given to the After School Director in advance, in order to prevent any confusions or problems.

Name: Phone: Relationship:
Name: Phone: Relationship:
Name: Phone: Relationship:

I acknowledge that I have read the Parent Handbook and give my consent to the following:
	1) Emergency medical care for my child as outlined by the facility's procedure manual. 2) Administration of medication as outlined by the facility's procedure manual. 3) Administration of minor first aid by trained staff. 4) Any walking excursions from and around the facility. 5) Transportation from school to Colonial Sports (After School Program only).

I understand that Colonial Sports reserves the right to terminate this agreement, if I fail to meet the terms of agreement. I consent to the terms of this contract and have been given a signed and dated copy of this agreement form. I understand that this contract is subject to change, relative to rates, policies and procedures.

* I accept these conditions. (checking this box serves as your online signature)

Section 2: Health History

1. List any known allergies (including bee stings, food & drug allergies).

2. List ALL medications the participant uses on a regular basis.

3. List any medical / dietary information necessary.

4. Does your child have any physical conditions which limit his/her participation in any activities?
If yes, please explain:

5. Is your child subject to seizures?
If yes, please explain:

6. Please list any additional information you feel we should know in order to better serve your child.

7. Please list Emergency Contact Person(s), in order of preference:

Name:	Phone:
Name:	Phone:

* Parent's Signature is required for each item below to indicate Parental Consent (checking each box serves as your online signature)
Obtaining Emergency Care
Administration of Minor First Aid
Transportation by the Facility

WAIVER:

I hereby waive and release any and all rights for myself, my heirs, executors and administrators this enrollee may have
against CHB Sports, Inc. or its representatives, agents and successors for any and all injuries the participant may suffer
in connection with his/her participation in any Colonial Sports Program.

* I accept these conditions. (checking this box serves as your online signature)

MEDICAL WAIVER:

We understand that in case of emergency and we are unable to be contacted, we give permission to Colonial Sports to
authorize any emergency action necessary to insure the safety of our child. This does not in any way hold CHB Sports, Inc.
financially responsible or otherwise liable for any medical or emergency care given.

Which hospital do you wish to use if need be?

PHOTOGRAPH WAIVER:

I grant permission for my child to participate and be photographed in any and all activities. I grant permission for any
photographs to be used in any Colonial Sports publications.

* I accept these conditions. (checking this box serves as your online signature)

* = required fields

If you have any problems or questions with this form, please contact us at webmaster@chbsports.com