Activity Participant Form Please complete this required form. Activity Participant Info Please complete this required form before the first session of the activity your child will attend. Thank you! Step 1 of 9 11% Child's Legal Name(Required) First Last Child's Preferred Name Child's Preferred Pronouns He/Him She/Her They/Them Other Please list your child's preferred "other" pronouns(Required) Parent/Legal Guardian Name(Required) First Last Parent/Legal Guardian Phone Number(Required)Parent/Legal Guardian Email Address(Required) Child Pick-Up & Emergency Contact Information(Required)Please list all adults, including parents/guardians, that are authorized to pick up your child from the activity. Children will not be released to anyone except those who are listed unless written confirmation is given to the Director. An ID will be required at the time of pick-up. This list of contacts will also be used in case of an emergency and/or if the parent/guardian cannot be reached. Click on the + to add more people to the list.Contact Full NamePhone Number 1Phone Number 2 Add Remove Primary Care Physician or other provider of medical care:(Required) Phone number for Primary Care Physician or other provider of medical care(Required)Are there any health problems including physical, psychiatric, or behavioral problems of which we need to be aware?(Required) Yes No Please explain physical, psychiatric, or behavioral problems.(Required)Are there any medications, dietary restrictions, allergies, or special needs that we need to be aware of to ensure that your child’s camp experience is positive?(Required) Yes No Please explain medications, dietary restrictions, allergies, or special needs.(Required)If your child requires medication, has allergies, has asthma, and/or is subject to seizures, please complete the additional relevant forms at the end of this form. Describe successful methods (if any) to avoid or discontinue unwanted behavior(Required)What calms your child when he/she is upset?(Required)Any other suggestions? Terms, Conditions, and Release of Liability Agreement(Required)I hereby acknowledge that I am over the age of 18, that I am the parent and/or legal guardian of the child (“Child”), or children registered for this event, and that I have the authority to make agreements on behalf of Child. I further acknowledge that I have voluntarily chosen to enroll Child in, or attend an event hosted by, STEAMazing / Pongos Learning Lab (“Club”) operated by Pongos Interactive, LLC (“Pongos”). I also give consent to Child’s participation in Club-related activities. I also acknowledge that all of the terms listed in this document apply to me, as well, when I attend an event. ACCEPTANCE OF RISKS AND RELEASE FROM LIABILITY I understand that certain risks are inherent in any recreational activity. I agree that there may be a risk of injury or harm to the Child as a result of Club activities, and I knowingly and voluntarily assume all risks of such injury or harm. I also understand and agree that it is my and the Child’s responsibility to safeguard his or her personal belongings, and I knowingly and voluntarily assume all risk that personal belongings brought to camp may be lost, misplaced, damaged, or stolen. I hereby waive and release Pongos (and its owners, agents, partners, representatives, employees, contractors, staff, and volunteers, as well as the same for Pongos and Club partner facilities) from any liability, including but not limited to claims based on negligence or some other act or omission, for any injury, illness, or harm to Child or damage of any personal property incurred while attending Club-related activities. SAFETY & CONDUCT For everyone’s safety, children must follow all staff instructions. I understand that if Child’s actions or attitude are deemed detrimental to other participants, staff, or the general atmosphere, he or she may be sent home without any reimbursement for any payment to Pongos. I agree to accept full responsibility, financially or otherwise, for the conduct of Child — including paying restitution for damage to equipment, property, and facilities, including the personal property of other participants. Pongos is not required or expected to protect Club participants from theft or damage to personal property. MEDICAL AUTHORIZATION & SPECIAL NEEDS I understand and agree that I am responsible for determining the Child’s medical, physical or other qualifications and suitability for participating in the Club and its activities. I agree to disclose to Pongos and Club staff any pertinent medical, physical, or other conditions and special needs that may affect Child’s participation in these activities. I understand measures will be taken to safeguard the health and safety of all participants; however, in the event of need, I hereby grant permission of Pongos or its authorized representatives to arrange for such medical care that the Child may require. This includes minor medical care by Pongos staff members. In the event of serious injury or illness, Pongos will call 911. Pongos will also use all reasonable efforts to contact the parent, guardian, and/or people listed as emergency contacts. I am aware that Pongos assumes no liability for the costs or provision of medical care in the event that care is needed during or after this program. GOVERNING LAW, JURISDICTION & BINDING ARBITRATION I acknowledge that this Agreement shall be governed in accordance with the laws of the State of Maryland. I consent to the exclusive jurisdiction and venue of the federal and state courts located in Maryland in any action arising out of or relating to this Agreement. This Agreement contains a binding arbitration provision, which may be enforced by me or by Company. I agree that any dispute arising out of or relating to this Agreement shall be settled by binding arbitration in lieu of litigation. The arbitration shall be held in the state/province and county in which the camp is held, and judgment upon the award rendered by the arbitrator(s) may be entered in any court of competent jurisdiction under this section. The prevailing party in the arbitration shall be entitled to recover expenses, including costs and reasonable attorney’s fees associated therewith. I hereby acknowledge that I agree to and will comply with the terms of the binding arbitration provision. Should any part of this Agreement be found invalid or not enforceable by a court of law, the remaining portion shall continue to be valid and enforceable. This Agreement constitutes the entire Agreement between Pongos and me (on behalf of the named minor). By signing below, I acknowledge that I have read and agreed to all the terms set forth in this Agreement. HEALTH POLICY By visiting Pongos, you voluntarily assume all risks related to exposure to illness and infectious diseases. To minimize the risk of exposure, we follow the CDC and Maryland Department of Health guidelines, and we will notify parents at drop-off if any additional measures such as masks are required on any given day (we will provide masks if you do not have them). On a day-to-day basis, the following policies are in effect: Children who are ill are not permitted to attend any events. Illness includes symptoms such as: Vomiting Loose stools/diarrhea Suspected communicable disease Nuisance conditions not currently being treated, e.g., ringworm, scabies, head lice Red, draining eyes Persistent runny nose with yellow/green discharge, accompanied by fever Productive cough, accompanied by fever Undiagnosed rash Children with a fever (> 100.3 °F) must stay home until they are fever-free for 24 hours without fever-reducing medication. Children with a known communicable disease are not permitted to attend any events without a doctor’s note. If your child becomes ill during an event, they will be isolated until a parent can pick them up. If a staff member contacts you to notify you that your child is ill, you must make arrangements for your child to be picked up in a timely manner. Failure to do so will result in dismissal from the program. I agree to the Terms, Conditions, and Release of Liability Agreement. Behavior Policy(Required)Pongos Learning Lab staff works hard to ensure that everyone has a safe, educational, and fun time while participating in our programs. Behaviors which disrupt staff from effectively supervising, instructing, or interacting with participants will not be tolerated. Such behaviors may include, but are not limited to: • Refusing to follow staff instructions, behavior guidelines, or program rules • Refusing to participate in activities or cooperate with staff • Using profanity, vulgarity, ethnic slurs, or obscenity • Leaving a program without permission • Excluding other participants • Teasing, making fun, or bullying of other participants or staff • Stealing or damaging property • Using equipment and materials inappropriately and/or without permission • Endangering the health and safety of children and/or staff • Threatening other participants or staff • Pushing, shoving, hitting, kicking, and/or biting other participants or staff • Using of illicit drugs, alcohol, or tobacco or sexual conduct of any kind Since many of our programs involve playing video games such as Minecraft, behavior that is deemed “griefing” in-game is strictly forbidden. This includes, but is not limited to, chat and/or mob spamming, flooding, malicious destruction, spawn killing, stealing equipment, unwanted building, purposely lagging, and trolling. The following actions will be taken if the above mentioned behaviors are observed: • Step 1: Staff will issue a verbal warning and redirect the participant to a more appropriate behavior. • Step 2: Staff will remove the participant from the group to discuss the behavior. • Step 3: Staff will remove the participant from the group for a time-out, and will notify the parent of the behavior. Notification will vary, depending on staffing, and might be done by phone, email, or in person. • Step 4: Staff will call the participant’s parent or emergency contact to have the participant picked up immediately. The above steps are generally taken, in the order listed, over the course of a single session of the program. In cases of particularly malicious and/or problematic behavior a step, or steps, might be skipped. In cases of physical altercations, participant will go directly to Step 4. If a participant gets to Step 4, he or she may return to the program for the next session only after discussion with the Director, but will be at Step 3 upon return. Participants who get to Step 3 or 4 more than once may be dismissed from the program, and might be barred from registering for future programs. No refunds will be issued in the case of dismissal from a program based on inappropriate behavior. Important: While we might tell the kids we have eyes in the backs of our heads, we really don’t. Retaliating against another participant is also considered disruptive behavior, so please encourage your children to speak up, and tell an instructor, if they are having problems. Please review this policy with your child, then each of you should sign below to indicate that you agree to follow this policy while at Pongos Learning Lab. I agree to the Behavior Policy and have reviewed it with my child. Late Pickup Policy(Required)Parents of participants enrolled in Learning Lab activities will be charged $1.00 per minute per child (maximum of $2.50 per minute per family) based on the program pick-up times listed for an event. • If you know you are going to be late please notify us so we can let your child and the teachers know. A late fee will still be charged. • If a parent or authorized pick-up person does not arrive or call by 5 minutes past the designated pick-up time, staff will assume an emergency exists and will begin to call emergency contacts for your child. • If no emergency contact can be reached within 30 minutes past designated pick-up time, staff may contact the local police department, who will pick up the child. • Late fees must be paid to staff upon pick up. • Continued disregard for the pick-up time or failure to pay late pick-up fees can be cause for the child’s termination from the program without refund. It is very important to always have updated contact information in your child’s file. Any child who is not picked up will be under the supervision of an assigned teacher/administrator until the parent, emergency contact, or the authorities arrive. All information about the incident will be discussed directly with the parent or guardian and never with the child. I agree to the Late Pickup Policy. Additional Forms(Required)If your child requires medication, has allergies, has asthma, and/or is subject to seizures, you must complete the additional relevant forms prior to the first day of the activity. You will find a link to the forms on the confirmation page for this form. I understand that it is my responsibility to complete additional forms if they are necessary. Signature(Required)By signing below you acknowledge that you are over the age of 18, that you are the parent or legal guardian of the child named in this form, and that you have completed this form completely and accurately.
