Extended Care Registration 2021-2022

Student Information
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Parent/Guardian  
Emergency Contact Information
The first attempt will be made to contact parents/guardians. Emergency Contacts listed below must be able to pick your child up in the event of an emergency.
Terms and Conditions of Enrollment
  1. No student will be properly enrolled in Symone Center for The Arts Program without the following paperwork completed and up to date: registration fee, participant application, payment, medical form, emergency form, and other required documents if your child has allergies, asthma or requires medication.

  2. No refunds will be granted if the participant leaves the program, on his/her own account or is removed from the program due to an inability to adjust or is unable to function adequately or to comply with the program rules. No refunds will be given for mandatory state, school, or program closures due to Covid-19. No refunds will be given for state, district, or program closures of any kind. There is no reduction or refunds based on missed days due to absence, illness or early withdrawal. All payments are due on the first of the billing month. Additionally, a one month deposit is due on the first day.

  3. The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact. Symone Center for the Arts, (SCTA), Inc. extended care has put in place preventative measures to reduce the spread of COVID-19; however, SCTA extended care cannot guarantee that you or your child will not become infected with COVID-19. 

  4. I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to myself my child (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I may experience or incur in connection with participation at SCTA. On my behalf, I hereby release, covenant not to sue, discharge, and hold harmless Symone Center for the Arts, Inc., its employees, agents, partners, and representatives, of and from the Claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any Claims based on the actions, omissions, or negligence of SCTA., its employees, agents, partners and representatives, whether a COVID-19 infection occurs before, during, or after participation at SCTA.

  5. I represent that I have adequate insurance to cover any injury or illness I, my child or family may suffer or cause while participating in this activity, or else I agree to bear the costs of such injury or illness myself. I further represent that I have no medical or physical condition which could interfere with my safety in this activity, or else I am willing to assume – and bear the costs of – all risks that may be created, directly or indirectly, by any such condition.

  6. In the event that I file a lawsuit, I agree to do so in the state where SCTA is located, and I further agree that the substantive law of that state shall apply. I agree that if any portion of this agreement is found to be void or unenforceable, the remaining portions shall remain in full force and effect.

  7. By signing this document, I agree that if I, my child or family is exposed or infected by COVID-19 during participation in this activity, then I may be found by a court of law to have waived my right to maintain a lawsuit against the parties being released on the basis of any claim for negligence.

  8. I have had sufficient time to read this entire document and, should I choose to do so, consult with legal counsel prior to signing. Also, I understand that this activity might not be made available to me or that the cost to engage in this activity would be significantly greater if I were to choose not to sign this release and agree that the opportunity to participate at the stated cost in return for the execution of this release is a reasonable bargain. I have read and understood this document and I agree to be bound by its terms.

  9. If I have signed a separate general waiver of liability connected to my participation at SCTA, I agree that the terms of that waiver are wholly incorporated into this document and that the terms of this document are incorporated into the separate general waiver.

  10. I agree that I, my child, and family will practice safe social distancing and clean hygiene during my participation at Symone Center for the Arts, Inc. 

  11. In consideration of                                          being permitted to participate in this program, I further agree to                                                                                                                                                                           indemnify and hold harmless Releasees from any claims alleging negligence which are brought by or on behalf of minor or are in any way connected with such participation by minor.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         

  12. For safety reasons, we must know, in advance, which children are expected to attend on any given day, no student will be permitted to attend the extend care program without being properly enrolled. 

  13. All late payments are subject to a $25.00 weekly late fee.

  14. Pick up is at 6:00 PM any child not picked up by 6:00 PM, the responsible party will be charged a $1.00 per minute additional fee for late pickup.

  15. A Registration Fee of $50.00 per participant is required for the extended care program.

  16. I am aware that my student must follow the rules and regulations of the program and may be terminated from Symone Center for The Arts program if he or she does not comply.

  17. I hereby consent to the taking of photographs, movies, Internet use, and videotapes, of my child Symone Center or its designated representatives. I also grant the right to edit, use, and re-use said products for any and all educational or public service I release any and all rights, title, and interest we or the child may have in said products. Photocopies and facsimiles of this Release and consent shall have the same legal effect as the original (Please indicate your permission below).

10. Symone Center for The Arts Summer Program is not responsible for any personal items that are lost stolen          or damaged while attending.

11. I consent that in an emergency Symone Center for The Arts may obtain medical treatment if necessary. I             understand that if medical treatment is deemed necessary I will be informed as soon as possible.

12. I reviewed the application and all the information provided is accurate and true. I agree to all the terms and         conditions.

13. I have received a copy of “A Parent’s Guide to Regulated Child Care.”

Health Information 
List any specific medical conditions or behavioral problems? Does your child have any other allergies (food, hay fever, etc)?
Are there any activities in which your child may not participate?
Are there conditions or specific needs that require special attention?
Will your child be taking medication during operational hours?

Please pack all medication in a sealed container, clearly labeled with your child’s name, age, medication, dosage and time and deliver to your child’s teacher for the week.


The information listed on this health information form is correct to the best of my knowledge, and the participant described herein has permission to engage in all prescribed program activities, except as noted on this form.


I, 

as parent/guardian, authorize Symone.

Center for The Arts personnel to seek emergency treatment as required and to transport my child to the appropriate medical facility in the event that urgent/emergency care is necessary.

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