: After School Club 2022 2023 - Event Registration

Afterschool Club Registration 2022 2023

INFO:

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Promotional Code

How would you like to pay?

When would you like to pay?

Registrant Fee:		$0.00
Group Fee:		$0.00
Registration Fee:
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Billing information

First Name

Last Name

Country

Address

City

State/Province

Zip/Postal

Phone

Billing and Payment
Billing and payment processing for Businesses' events is performed by Member Solutions, Inc. ("MSI"), and this contract is specifically assigned to MSI for all such purposes. Customer knowingly and irrevocably authorizes MSI to charge electronically Customer's bank account and/or credit card for any and all amounts due for Customer's, and anyone registering under Customer's, attendance and participation in the Event. Please note, you may see all or any portion of the following on your bank or credit card statement: "MSI*EDGERTONEXPLORITCENT 8882448044 ONLINE REG FEE". Any returned payment will be assessed a $25.00 fee. Any unsuccessful electronic transaction is subject to a $10.00 processing fee. MSI is not responsible for any bank fees incurred by Customer. MSI has the sole right to resubmit returned or declined items (plus applicable fees) without prior notice. BILLING INQUIRIES -- 888-244-8044 or by mail to PO Box 297, Hatboro, PA 19040.

Applicant Agreement
I represent that I am the person who appears on the application above. I acknowledge and agree to the statements, terms and conditions above, as well as any applicable terms and conditions for this registration, and that by typing my name below and completing this registration form, I am electronically signing the document, which will have the same legal effect as the execution of the document by a written signature and shall be valid evidence of my intent and agreement to be bound.

Applicant Signature
Please enter your full name in the space below.

Please click the button below to finalize your registration.

Registration inquiries:
Mary Molliconi
mary@edgerton.org
(402) 694-4032

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Registrant

use this registrant for billing information

Student Information

Student's First Name

Student's Last Name

Grade Level for 2022/2023

The Edgerton After-school Club has a couple options for students.

K-5

We will offer a healthy snack, physical activity, STEAM activities and hands-labs, arts and crafts, monthly field trips and lots of fun.

Middle Schoolers

For our middle school students who are interested in volunteering and helping. We love working with these students as they grow into great leaders.

Which After-School Club

Student Cell (if applicable)

Select T-Shirt Size

When is the student's birthday?

Please let us know any important medical or health issue we need to know to help your child.

Allergies/Asthma
Health Issues
Behaviorial Issues
Anxiety/ADHD
Special Learning Needs

Program Information

Program will run from 2PM-5PM but facilities will be open until 5:30PM. What time will you pick up your child(ren)?

Please list the individuals who are allowed to pick up your child.

Please list those individuals who are allowed to pick up your child from the Afterschool Program.

Parent Information

Parent's First Name

Parent's Last Name

Mobile Phone

Home Phone

Email (to confirm registration)

Address

City

State

Zip

Is the child's address different

What is the child's address

Emergency Contact and relationship to student

Provide name, relationship to camper and phone number for the best person to contact in case of emergency

Emergency Contact Cell Phone Number

Membership

Are you currently a member

Would you like to renew your membership ($99)?

Terms

Edgerton Explorit Center Terms, Conditions, and Release of Liability Agreement

I, the undersigned, parent or guardian of the child(ren) named above do hereby consent his/her/their participation in the Edgerton Explorit Center Afterschool Program. I acknowledge that participation in the program may expose the above named student(s) to possible injury. I agree to waive and release the Edgerton Explorit Center from all claims of damages that may arise. I authorize the Edgerton Explorit Center and other organizations affiliated with their Afterschool Program to use photographs of my child(ren) on Facebook, their website, promotional brochures and at the center.

I also give permission to transport or walk my child(ren) to special events and field trips off site during the Afterschool Program. I acknowledge that my child(ren) is expected to behave in an appropriate and respectful manner and participate in all activities. If inappropriate behavior issues are consistent, my child(ren) will be asked to take a break from the program until the problems have been addressed, corrected and resolved.

Check this box to indicate that you have read and agree to all of the above terms & conditions

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