Powerful Kids Child Care Limited: After School Registration 2024/2025

After School Registration 2024/2025

Venue

226 Waverley Road, Dartmouth NS B2X 2C4

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INFO:

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Registrant Fee:		$0.00
Group Fee:		$0.00
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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*GRASSHOPPERS 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:
Master Phil Power
(902) 455-4853
www.grasshoppers.ca

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Registrant

use this registrant for billing information

Child First Name

Child Last Name

Gender

How does the child identify?

Date of Birth

Address

City

Postal

Parent Information

Parent 1 Name

Parent 1 Cell Phone Number

Parent 1 Email

Parent 1 work location (name of business & civic address)

Example -
Grasshoppers, 226 Waverley Rd

This is needed in case of emergency and we had to send someone to your location.

Parent 1 work phone number

Parent 2 Name

Parent 2 Cell Phone Number

Parent 2 Email

Parent 2 work location (name of business & civic address)

Example -
Grasshoppers, 226 Waverley Rd

This is needed in case of emergency and we had to send someone to your location.

Parent 2 work phone number

Emergency Contact Information

_{^{(should we be unable to contact either parent, we require an emergency contact person)}}

Emergency Contact Name

Emergency Contact Cell Phone Number

Relationship to family

Medical Information

Does your child have ADD / ADHD / ODD / Autism etc?

Please Explain

Is your child on any prescription medication?

Please list all medications / doses / timings

Does your child have any medical risks or allergies:

Please specify medical condition

Can your child be given childrens tylenol, if required, by staff?

Pick up Information

What school does your child attend?

Who is authorized to pick up your child?

Please specify who is able to pick up your child and their relationship to the child. There is no need to put the parents on here, but do require grandparents etc.

Are their any custody battles concerning your child?

Will your child be attending our PD day camps?

There are no cost for PD day camps that follow the regular school year. This is to help us judge how many children will utilize this service and staffing levels etc.

Will your child be attending any of our 1 week day camps?

Note - Cost is additional for one week camps. Approx $230 tax included per camp

Program Information

Are you a returning student?

Do you have another child attending Grasshoppers A/S?

What is the siblings name

Will your child be doing TaeKwonDo?

Will your child be doing day or night TaeKwonDo?

What belt level is your child

All new students must undergo an interview and orientation process. Has you chip had an interview with our staff members yet?

Have you done an in class assesment yet?

Payment Information

Grasshoppers uses a payment processing company called Plooto. Do you agree to have monthly payments debited from your account from September to June?

Do you still have your key fob for the upcoming year?

I understand that the monthly amount for childcare is $365 for one child and $675 for two children. This is based on the 10 month contract

I understand that should I not not notify Grasshoppers when my child is absent or if I am late for pickup that there is a $25 fee per occurrence?

Terms

After School Registration Contract 2024/2025 School Year
Legal Disclosure and Contract.

I agree that once i have paid my registration fee that there are are no refunds or transfers.

I am signing up my child(ren) for the ENTIRE 2024/2025 school year. Should I wish to cancel this agreement it can only be done so with written consent of both parties and a 3 month penalty will be billed.

All associated program costs must be paid in advance of service rendered. All payments will be debited through automatic withdrawal and I agree that the amount selected will be debited until the contract ends in June of 2025. Any late payments or arrears will also be automatically debited from my account.

I have read and fully understand the terms and conditions set out by Powerful Kids Child Care Limited. This includes but is not limited to this contract, medical release, Parents handbook, pricing schedule, and pre authorized debit information.

I agree, on behalf of the above named child, his/her heirs and representative to fully and forever release, and hold harmless Powerful Kids Child Care Limited, the After School Program, its agents, servants, and employees from any and all claims, demands, rights of action of causes of action, present or future, whether the same be known, anticipated or unanticipated, resulting from or arising out of transportation, participation or enrolment in this program.

A qualified Instructor, Assistant Instructor, or Junior Instructor conducts all classes. All curriculum and techniques are supervised, but sometimes are more difficult for certain individuals. Please consult your doctor before starting any classes. After consulting your physician, if at any time you feel shortness of breath, pain, or discomfort, please feel free to step out of class and consult an instructor or physician. Powerful Kids Child Care Limited can not be held legally responsible for any misuse, negligence, or injury that may result from transportation, instruction or participation at Powerful Kids Child Care Limited

By signing this I understand and agree with all the terms and conditions set forth by Powerful Kids Child Care Limited Program for the 2024/2025 school year.

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

Electronic Signature

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