Parents' Night Out - Quantum Athletics

Fee: $23/full day | $15/half day (4 hours or less) | $50 deposit

Campers Name*

First Last

Age*

Date Of Birth*

MM

DD

YYYY

Grade Completed*

Gender*

Parent / Guardian Information

Parent/Guardian Name*

First Last

Work Phone*

Cell Phone*

Email*

Address*

Street Address Address Line 2 City ZIP / Postal Code

Parent/Guardian Name

First Last

Work Phone

Cell Phone

Address

Street Address Address Line 2 City ZIP / Postal Code

Emergency Contact Information

Emergency Contact #1*

First Last

Phone*

Address*

Street Address Address Line 2 City ZIP / Postal Code

Emergency Contact #2*

First Last

Phone*

Address*

Street Address Address Line 2 City ZIP / Postal Code

Pickup Authorization

Who may pickup your child besides parent/guardian(s) listed above?*

(please include emergency contacts, if applicable)

Health Record

List all allergies, any special precautions and treatment indicated for these allergies (i.e., food, medication or environmental allergies).*

(please be sure to include ALL food allergies. type N/A if this question is not applicable)

List all medications or modified diets currently being administered to your child. If Quantum staff will need to administer medication, please place information below.*

(type N/A if this question is not applicable)

List any chronic physical problems and any history of hospitalization.*

(type N/A if this question is not applicable)

List any diseases that your child has had.*

(type N/A if this question is not applicable)

List your child’s current interests:*

(e.g., sports, bugs, frogs, dancing, reading, singing, etc.)

What days to you plan to attend each week?*

(days can vary each week, as long as your child attends on a regular basis)

Select All
Monday
Tuesday
Wednesday
Thursday
Friday

What size T-shirt does your child wear?*

Policy Agreement

1. I give permission for my child to participate in Summer Camp activities such as group led enrichment, swimming, movies, field trips, etc. both on and off location.

2. I give permission for my child to be included in pictures or other publicity connected with the camp, including Instagram, Facebook and other social media platforms.

3. I will purchase a pool pass to the Lockwood Pool for my child or send the daily admission fee. Daily admission fees will be charged to statement if money is not sent for daily admission.

4. I understand that if my tuition is not up to date, my child will be unable to continue attending until the balance is caught up.

5. We will run on a three strike policy this summer: The third time a problem behavior has to be reported to a parent, they will be no longer able to attend

*

I HAVE READ AND UNDERSTAND THE POLICY AGREEMENT*

Credit/Debit Card Agreement

Quantum policy requires that all clients have a credit or debit card on file for payment purposes. Your Credit/Debit Card information will be secure and can only be charged under the terms you specify below.

By providing us with your Credit/Debit Card Information, you authorize Quantum to automatically charge your card on a weekly basis if another payment is not secured. Cards will be run each Friday for the following week.

If the Credit/Debit Card information on file changes for any reason, you must notify Quantum as soon as possible. We will maintain a clear record of all payments and charges. However, in the rare case that an overpayment occurs, your account will be credited on the upcoming invoice or if the balance is zero and you no longer bring your child to Quantum, your Credit/Debit Card will be reimbursed. An email receipt will be sent to you as soon as the payment goes through. In the event of a declined charge, you will be asked for a new Credit/Debit Card number and/or alternate payment before your child can return to Quantum.

*

I HAVE READ AND UNDERSTAND THE CREDIT/DEBIT CARD ON FILE AGREEMENT AND AUTHORIZE QUANTUM ATHLETICS TO CHARGE MY CREDIT/DEBIT CARD A $50 DEPOSIT AND OTHER FEES AS STATED ABOVE.*

Credit Card Number*

Expiration Date*

Security Code*

Cardholder Name*

First Last

Parent/Guardian Signature*

Date

MM

DD

YYYY