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Kid Zone & Youth Zone Registration

Kid Zone and Youth Zone are open to MJCCA members and non-members.

Participant Information

First Name*
Last Name*
Gender*
 Male
 Female
Date of Birth* (MM/DD/YYYY)
Address*
Address 2
City*
State*
Zip*
Child Lives With*
Name of siblings in Kid Zone or Youth Zone (if applicable)
Does your child have any food or medical allergies?*
 Yes
 No
If yes, please list all allergies.
Does your child have any dietary restrictions?*
 Yes
 No
If yes, please list all dietary restrictions.
Does your child or has your child ever received any medical or educational therapies (PT, IT, Speech, etc.)?*
 Yes
 No
If yes, please list therapies and last session dates.

Parent/Guardian Information

What is your relationship to the child?*
 Parent
 Guardian
Marital Status*
 Married
 Separated
 Divorced
 Widowed
 Single
For divorced parents or legal guardians: Who has legal custody of this child?*

Parent/Guardian #1

First Name*
Last Name*
Home Phone* (XXX-XXX-XXXX)
Cell Phone* (XXX-XXX-XXXX)
Work Phone* (XXX-XXX-XXXX)
Email*

Parent/Guardian #2

First Name
Last Name
Home Phone
Cell Phone
Work Phone
Email

Emergency Contact Information

Emergency Contact #1

Relation to Child*
First Name*
Last Name*
Home Phone* (XXX-XXX-XXXX)
Cell Phone
Work Phone

Emergency Contact #2

Relation to Child*
First Name*
Last Name*
Home Phone* (XXX-XXX-XXXX)
Cell Phone
Work Phone

Permission & Waiver

I give permission for my address, phone numbers and email to be released to other Kid Zone and Youth Zone families.*
 Yes
 No
I hereby authorize MJCCA to include my child in supervised water activities (if applicable).*
 Yes
 No
Should the need for medical attention arise (and in case of unavailability), as parent or legal guardian, we give authorization to the MJCCA and/or staff to arrange and authorize medical treatment as necessary for our child.*
 Yes
 No
Child's Medical Insurance Co.
Insurance Group #
Insurance ID #
I have read and fully understand the MJCCA Kid Zone/Youth Zone Policies (click here to view Kid Zone/Youth Zone Policies).*.
 Yes
 No

Waiver

 I HAVE READ THE MARCUS JEWISH COMMUNITY CENTER OF ATLANTA RELEASE, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY MY SIGNING IT, AND HAVE SIGNED IT FREELY AND VOLUNTARILY WITHOUT INDUCEMENT, ASSURANCE OR GUARANTEE BEING MADE TO ME AND INTEND MY SIGNATURE TO BE A COMPLETE, CONTINUING AND UNCONDITIONAL RELEASE OF ALL LIABILITY TO THE GREATEST EXTENT OF THE LAW.

Payment

Kid Zone/Youth Zone Account: If you choose to create a Kid Zone/Youth Zone Account your account balances will be automatically charged on the first of every other month to the credit card you provide. We do not process ANY payments on weekends. A courtesy balance will be provided upon request before the cards are charged.

Would you like us to set up a Kid Zone/Youth Zone Account for your payments?*
 Yes - Use payment to process payment monthly.
 No - Use payment for child's first visit only.
Is this billing address the same for the credit card or EFT/Bank Account as the address for Parent 1?*
 Yes - Skip to select "Method" of payment below.
 No - Fill in the address fields below.
Address
City
State
Zip
Method of Payment*

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