Lazer X - The Family Zone

Child’s Name:________________________________________Birthdate:__________________

Home Address:_________________________________________________________________

Email:________________________________________________

Father’s Name:___________________________________ Contact Number:_______________

Mother’s Name:__________________________________ Contact Number:_______________

How did you hear about us?______________________________________________________

If friend referred you, what is their name:___________________________________________

Persons Authorized to Pick up your Child if the following occur: (Lazer X requires an ID that matches any of the names on this from before we will release a child)

• A medical emergency occurs and you can’t be reached

• If it is closing time & we can’t reach parent(s)/guardian

• If staff is unable to reach parent(s)/guardian

• Parent(s)/guardian is unable to pick up child

Name:__________________________________________ Contact Number:________________

Address:_______________________________________________________________________

Relation to Child:________________________________________________________________

******************************************************************************

Name:__________________________________________ Contact Number:________________

Address:_______________________________________________________________________

Relation to Child:________________________________________________________________

******************************************************************************

Name:__________________________________________ Contact Number:________________

Address:_______________________________________________________________________

Relation to Child:________________________________________________________________

******************************************************************************

Parent Instruction and Consent

My Child is in Grade? _____________ Note: Lazer X will only accept school aged children in grades 1 and up.

Is your child toilet trained?____________ Note: Lazer X will not accept any children that are not toilet trained.

Does your child have any Allergies? If so, please list: ___________________________________

Any behavioral or Developmental Concerns:__________________________________________

I understand that Lazer X does not supply any snacks and it is my responsibility to provide my child with snacks from home. Lazer X will have water available at all times. Please label all food/drink containers with your child’s name.

⭐︎⭐⭐︎⭐⭐︎⭐⭐︎⭐⭐︎⭐⭐︎⭐⭐︎⭐⭐︎⭐⭐︎⭐⭐︎⭐⭐︎⭐⭐︎⭐⭐︎⭐⭐︎⭐⭐︎⭐⭐︎⭐⭐︎⭐⭐︎⭐⭐︎⭐⭐︎⭐⭐︎⭐⭐︎⭐⭐︎⭐⭐︎⭐

Agreements:

I understand that in some emergency situations, Lazer X will need to contact the emergency medical service before the parent, child’s physician, and/or other adult acting on the parent/guardian’s behalf. In the event of a medical emergency, I understand that my child will be transported to the nearest hospital if the local emergency medical unit determines it is necessary for treatment.

I hereby grant permission to the Lazer X staff to take whatever measures are judged necessary for the care and protection of my child while under their supervision. I understand that it is my responsibility to keep the information on this form up to date. Lazer X is not liable if this information is inaccurate or outdated.

• I understand that Lazer X will bill in 30 minute increments.

• I have received a Parent Handbook and agree to follow all guidelines listed.

• I understand I must stay within 15 minutes of Lazer X in case I am called for pickup.

• I will honor the Sick Policy in the Parent Handbook (also posted by the front desk).

NAME:_________________________________________________

SIGNATURE:_____________________________________________DATE:__________________