Adventure Quest Registration

Child Information
Name of Child
Nickname
Gender: Male Female
Date of Birth (Enter as MM/DD/YYYY)

Street Address
City
State
Zip Code

Contact Phone (123-456-7890)
Parent's Email Address
Name of Elementary School

Enrollment Information
Which Campus Are You Registering For? Suwanee Duluth
Attendance Will Begin (MM/DD/YYYY)
Days of Attendance : M T W Th F

Parent Information - Mother Mother's Name
Telephone
Home Address (if different from child)
City
State
Zip Code
Employer
Work Hours
Work Address
City
State
Zip Code
Work Telephone

Parent Information - Father Father's Name
Telephone
Home Address (if different from child)
City
State
Zip Code
Employer
Work Hours
Work Address
City
State
Zip Code
Work Telephone

Drop Off/ Pick-Up/ and Release Information Parents, or persons authorized by the parents to pick up or drop off their child at Adventure Quest, must escort the child into or out of the center. Adventure Quest will not allow any child to enter or leave without an escort. Other persons to whom Adventure Quest is authorized to release this child to shall be listed below. Under no circumstances will Adventure Quest release this child to anyone not identified below or not otherwise known to the staff, without specific authorization from the parent or guardian. Additions or changes to this list of persons appearing below will be made, signed and dated on this form or shall be attached. The parent or guardian agrees in each instance that he/she will be certain the staff is aware of the child’s arrival and departure.

Name
Relationship
Address

Name
Relationship
Address

Name
Relationship
Address

Emergency Contacts Persons whom you authorize Adventure Quest to contact for guidance in an ency such as a medical or other ency, when the child’s parents or guardian are unavailable, shall be listed below:

Name
Relationship
Phone (123-456-7890)

Name
Relationship
Phone (123-456-7890)

Name
Relationship
Phone (123-456-7890)

Health Information Describe any health or other situations concerning your child that Adventure Quest personnel should be aware of, such as food/drug allergies, dietary restrictions, and/or medications that your child is currently taking:

Physician Information Please list the name and telephone of the physician you wish for us to contact in an ency situation.

Physician Name
Phone (123-456-7890)

Immunization Information In order to comply with state law, it will be necessary for the parent or guardian to supply Adventure Quest with an immunization report no later than thirty (30) days after the actual attendance begins. The child’s continued enrollment will be predicted upon our being provided with updated immunization reports as they become due.

Medical Authorization We understand that consistent with the circumstances of the situation and available time, if a child is injured or becomes ill, Adventure Quest will attempt to contact and follow the instructions of the parent or guardian, physician or other person(s) designated as outlined above. In the event Adventure Quest is unable to contact the parent, guardian, physician or ency contact person(s), we hereby grant permission to Adventure Quest to contact and comply with the advice of an available physician, ambulance personnel, or ency room personnel. We hereby agree that we will be solely responsible for an will promptly pay any expenses which may be incurred by Adventure Quest in making ency medical treatment available to the above mentioned child. I understand that Adventure Quest uses Gwinnett Medical Center for all ency medical situations.

Child Illness Procedure If your child appears ill, has a fever over 101 degrees, is vomiting or showing evidence of a communicable disease, please do not bring them to Adventure Quest. If any case of a communicable disease is reported to Adventure Quest, you will be notified. If your child has symptoms and is present at Adventure Quest, they will be extracted from the general population of children and you will be asked to pick him/her up immediately. Children must be without a fever for 24 hours without the use of Tylenol, etc. before returning. The Director reserves the right to ask for physician’s approval before readmission will be authorized in certain cases.

Medical Administration The staff will administer medicine to the child upon written authorization only by the parent or guardian. Written authorization may be made by using the standard Adventure Quest medication form. In each case, the parent or guardian should complete, sign and date the form and deliver it with the labeled medication to the Director. Under no circumstances should any medication ever be left in a child’s bag or taken into the classroom. Any adverse reactions to the medication will be immediately reported to the child’s parents and physician.

State law requires that all medications must be:

In the original container.
Clearly labeled with the name of the child and the name of the medicine.
If a prescription, labeled with a prescription number.
Clearly labeled with the date and the dosage to be administered.
If it is an over the counter medication (Tylenol, Advil, etc.) you must bring a written prescription from the doctor before administering.

Program Acknowledgement and General Authorization We have reviewed with the Director of Adventure Quest (or the designee) the daily programs and policies of Adventure Quest. We hereby grant permission to Adventure Quest for the above named child to participate in the following.

Take part in all programs activities, including the use of indoor and outdoor equipment.
Be photographed or videotaped in connection with the daily program activities.
Children 5 years of age and older may leave the premises of Adventure Quest to take part in planned educational and recreational field trips or activities supervised by the staff of Adventure Quest. These field trips will be separately announced to the parent or guardian at least one week in advance of the field trip or activity and they will be asked to sign an authorization form allowing the child to participate.
If applicable, be transported to and from the elementary school the child attends.
Participate in water-related activities supervised by the staff of Adventure Quest.

Enrollment Policy and Agreement Initial and continued enrollment will be at the discretion of Adventure Quest based upon the best interests of the child, the expectations that he/she will benefit from the program and the welfare of the other enrolled children. Enrollment shall be without regard to race, creed, sex, or national origin. A copy of this enrollment agreement will remain within the files of Adventure Quest so long as the child remains actively enrolled at the school and shall be available for inspection by the parent or guardian at any time. Information in the child’s file must be kept current at all times. The parent or guardian is required by law to update the information furnished herein as necessary, with changes initialed and dated by the parent and the Director (or designate). Continued enrollment is predicated on your agreement to notify the school of any change in phone numbers, address, ency phone numbers, family physician, allergies information, etc.

Hours and Days of Operation Adventure Quest serves children from 5 years old to 14 years old with the hours of operation being from 6:30AM to 8:15AM and 2:30PM to 6:30PM Monday through Friday. Holiday and Camp hours will be 6:30AM to 6:30PM Monday – Friday. A late fee of $1.00 a minute will be assessed after 6:30pm.

Registration Fees & Tuition Payment

An annual and non-refundable registration fee of fifty dollars ($50.00) shall be charged for each child at the time of enrollment. This is an annual fee that will be charged every 12 months from the enrollment date.
A 10% sibling discount is available for families that have multiple children enrolled in the before and after school program.
The Parent or guardian agrees to pay all charges no later than Tuesday for all anticipated fees to be incurred that week.
Payments are considered delinquent if not received by 6:30PM and a late fee of $10.00 will be assessed. Failure to pay the current week’s tuition or chronic problems with not paying in a timely manner may require the child to be removed from our program until appropriate arrangements have been made. The parent or guardian shall remain responsible for all balances due and any expenses incurred by Adventure Quest in the pursuit of such payment.

Acceptable methods of payment are cash, check, or credit card (MasterCard or VISA). If a check is returned unpaid by the back, a service charge of thirty dollars ($30.00) will be assessed.

Before and After School- $85.00
Before School Only - $50.00
After School Only - $70.00
Early Release for Before & After is $10.00 additional to the regular rate
Early Release for Before or After is $12.00 additional to the regular rate

Tuition is subject to increase annually

Withdrawal The obligation for full payment of tuition and other fees will continue until the date indicated by the parent or guardian as the date of withdrawal. All withdrawal notices must be put in writing and handed either to the director or other designated Management personnel. The parent or guardian agrees to furnish Adventure Quest with at least 2 weeks advance written notice of such date of withdrawal. If parent or guardian fails to provide notice, the parent or guardian remains responsible for the full tuition for the (2) weeks after the child’s last day of attendance plus any late charges or penalties which should accrue until full payment is received. The parent will also be held responsible for any and all expenses incurred by Adventure Quest in pursuit of payment. In any situation in which the child is temporarily withdrawn from Adventure Quest by using the above outlined procedures and regular payment of tuition has been temporarily suspended, the enrollment will be terminated. Re-enrollment will be based on availability of space.

Transportation Adventure Quest provides transportation to and from local schools in our area. We will use a van/bus that is owned by Adventure Quest to provide any transportation to and from local schools as well as on field trips. If your child is going to be picked up and dropped off by Adventure Quest, please inform the school that they attend.

Authorization Signatures

Our signature below indicates that we have reviewed this agreement in its entity and agree to all of the statements and provisions made herein. Items outlined in this agreement may not be changed, waived, discharged or terminated orally, but only by a written agreement that is signed by both the parents and Adventure Quest. In addition, all information we have provided in this agreement is true and accurate to the best of our knowledge. Any changes in significant information such as addresses, telephone numbers, allergy information, and etc. will be updated in a timely manner.

Parent/Guardian Signature
(By typing your name, you are signing this agreement)
Date