Parent/Guardian 1 First Name:
Parent/Guardian 1 Last Name:
Parent/Guardian 1 Email:
Parent/Guardian 1 Cell Phone:
Parent/Guardian 2 First Name
Parent/Guardian 2 Last Name:
Parent/Guardian 2 Cell Phone:
Parent/Guardian 2 Email:
Emergency Contact Information (not a parent)
Full Name
Cell Phone:
Participant Information
Child First Name:
Child Last Name:
Child's Date of Birth:
Child's Grade:
Kindergarten 1st Grade 2nd Grade 3rd Grade 4th Grade 5th Grade
If yes, please explain:
If yes, please explain:
Please select the ASP Program that your child will attend:
Transportation Only Transportation and After-Scholl Program until 6:00 p.m. On Friday, until 5:30 p.m. Walk-Over Only (Hillel, Bridge Prep, and Ojus) Walk-Over and After-School Program until 6:00 p.m. On Friday, until 5:30 p.m
School Attending
Aventura Waterways K-8 Center Highland Oaks Elementary Hochberg Preparatory School - Posnack East Ben Gamla Charter School Hollywood - Currently Sold Out. Register for waiting list (weekly registration only) Scheck Hillel Community School Ojus Elementary School Bridge Prep Academy Aventura Charter Elementary School - Waiting List
Please indicate your child's school dismissal time:
If yes, please provide the day, time, and name of the enrichment class:
Immunization Form (Your child must be fully vaccinated to participate in the After-School Program. Religious or other exemptions are not accepted)
If yes, please enter the last four digits of your credit card on file:
Please select credit card type
Visa Mastercard Amex Discover
Cardholders Name:
Card Number:
Expiration Date (Month/Year):
CVV:
Minor Participant Waiver, Release, Indemnification of All Claims & Covenant Not to Sue NOTICE: THIS IS A LEGALLY BINDING AGREEMENT. Read this document carefully and in entirety. By signing this agreement, you give up your right, and the named minor’s right to bring a court action to recover compensation or obtain any other remedy for any personal injury or property damage however caused arising out of your child's participation in Michael-Ann Russell JCC (MARJCC) Programs, now or any time in the future. I, in my legal capacity as the parent/guardian of the minor named below, do hereby acknowledge and agree that participation in MARJCC activities comes with inherent risks. I have full knowledge and understanding of the inherent risks associated with MARJCC participation, including but in no way limited to (1) slips, trips, and falls, (2) aquatic injuries, (3) athletic injuries, and (4) illness, including exposure to and infection with viruses or bacteria. I further acknowledge that the preceding list is not inclusive of all possible risks associated with MARJCC participation. That said list in no way limits the operation of this Agreement.
Coronavirus/COVID-19 Warning & Disclaimer Coronavirus, COVID-19 is an extremely contagious virus that spreads easily through person-to-person contact, through airborne particles transmitted from one person to another, and from surfaces contaminated with the virus. Federal and state authorities recommend social distancing, wearing personal protective equipment such as a mask, frequent hand washing, and avoiding public gatherings as means to reduce the risk of contracting the COVID-19 virus or spreading the COVID-19 virus. COVID-19 can lead to severe illness, personal injury, permanent disability, and death. Participating in MARJCC programs or accessing MARJCC facilities could lead to, or increase the risk of, being exposed to, or contracting COVID-19. I acknowledge and understand that, by participating in any program offered by the MARJCC, I may be increasing the risk that I will be exposed to COVID-19 or that I may become infected with COVID-19 through contact with another person, through airborne particles transmitted from one person to another, from surfaces contaminated with the virus, or by some other means. By my initials near this paragraph and by my signature on this Agreement, I acknowledge and assume the risk described in the preceding sentence, I agree to follow federal and state guidelines to avoid contracting or spreading the virus, and I agree to hold the MARJCC harmless in the event I contract COVID – 19 through my participation in a program offered by the MARJCC or by some other means. The MARJCC expressly disclaims any warranty or guarantee that COVID-19 infection will not occur through participation in MARJCC programs or accessing or being present in MARJCC facilities.
Waiver, Release, Indemnification & Covenant Not to Sue In consideration of my child's participation in any MARJCC programs, I, the parent/guardian of the minor named below, agree to release and on behalf of myself and the minor named above, my heirs, representatives, executors, administrators, and assigns, HEREBY DO RELEASE MARJCC, its officers, directors, employees, volunteers, agents, representatives and insurers (“Releasees”) from any causes of action, claims, or demands of any nature whatsoever including, but in no way limited to, claims of negligence, which I, the named minor, my heirs, representatives, executors, administrators and assigns may have, now or in the future, against MARJCC on account of personal injury, property damage, death or accident of any kind, arising out of or in any way related to the use of MARJCC facilities/equipment or participation in MARJCC programs whether that participation is supervised or unsupervised, however the injury or damage occurs, including, but not limited to the negligence of Releasees. I understand and agree that this release includes any claims based on the actions, omissions, or negligence of MARJCC, its employees, agents, and representatives, whether a COVID-19 infection occurs before, during, or after participation in any MARJCC program.
In consideration of the named minor’s in the MARJCC programs, I, the undersigned parent/guardian of the named minor, agree to INDEMNIFY AND HOLD HARMLESS Releasees from any and all causes of action, claims, demands, losses, or costs of any nature whatsoever arising out of or in any way related to the named minor’s participation.I hereby certify on behalf of myself and the named minor that I have full knowledge of the nature and extent of the risks inherent in the named minor’s participation and that I, certify on behalf of myself and the named minor, am voluntarily assuming said risks. I understand that I and the named minor will be solely responsible for any loss or damage, including personal injury, property damage, or death, the named minor sustains while participating in the MARJCC and that by signing this agreement I, on behalf of myself and the named minor, HEREBY RELEASE Releasees of all liability for such loss, damage, or death. I further certify that the named minor is in good health and has no conditions or impairments which would preclude his/her safe participation in the MARJCC.I further certify that I am therefore of lawful age (18 years or older) and otherwise legally competent to sign this agreement, and that I have legal capacity to act as the parent/guardian of the named minor. I further understand that the terms of this agreement are legally binding and certify that I am signing this agreement, after having carefully read it, of my own free will.
Code of Conduct 1. Be active listeners, cooperate, and follow directions given by ASP staff, supervisors and at all times. 2. Treat fellow participants, staff, supervisors, guests, public/private property and the environment with the utmost respect. We expect every participant to exercise goodwill towards others, our activities and facilities. Courtesy and respect are requirements of the MARJCC community. 3. Refrain from using rude, offensive or generally bad language. Harsh verbal words, tone of voice, foul language or gestures will not be tolerated. 4. Keep hands and bodies to themselves. If physical contact is made with another person, it must be both welcomed and appropriate. Teasing, horseplay, pushing, kicking, hitting, fighting, bullying or harassment will not be tolerated. 5. Refrain from bullying, cyber bullying and/or harassment. 6. Refrain from taking part in physical acts of a sexual nature, engaging in sexual harassment, or offending others by indecent exposure. 7. Refrain from damaging, destroying, or vandalizing program or JCC property. 8. Stay with the group, at all times. No child is permitted to leave the group without his or her counselor’s permission and direct supervision. 9. Refrain from bringing fireworks, firearms, toy guns or weapons of any kind to the ASP/JCC. 10. Refrain from bringing or using any illegal drugs, tobacco, alcohol or intoxicants of any kind. 11. Cell phones and other mobile communication device usage (except in authorized activities) are strictly prohibited during the day. Other electronics, such as iPads, iPods, video games, laptops, etc., are prohibited. MAR JCC is not responsible for theft or damage to any child’s personal property. 12. Participants will be expected to participate in all scheduled program activities unless exempt because of health or parental restriction. Explanation must be in writing. 13. There is a zero-tolerance policy for theft. 14. Social Media: When utilizing social media platforms such as “What’s App," “Instagram,” “Snapchat,” and other venues that are public vehicles of speech and photos alike, rules exist that we must all (children and parents) recognize, understand and follow. There will be consequences when these rules are not followed and respected. a. One may not promulgate negative, unkind verbiage about other participants, other parents, or JCC personnel on social media. b. One may not post pictures of another parent(s)’ child(ren) without parental permission. c. One may not “condemn” the JCC or the JCC policies or staff decisions. NOTE: It is not possible to anticipate every possible situation that may arise. In the absence of a particular situation or activity not listed above, COMMON SENSE AND COURTESY SHALL PREVAIL. MAR JCC implements a system of participants monitoring in its effort to provide an incomparable experience for all of its participants. If MAR JCC determines that a participant is failing to adhere to this Code of Conduct, or presents a safety, behavioral or other concern that is detrimental to the child, other participants, staff or employees, or to the overall program experience, our program reserves the right to enforce consequences. These consequences may include, but are not limited to: limitation of privileges, verbal and/or written warnings, parental notification, or, in extreme cases, expulsion from the program (without refund). Additionally, participants who repeatedly fail to adhere to the Code of Conduct may run the risk of not being allowed to attend the program or any MAR-JCC activities in the future.
General Consent and Signature I, as an individual, or as a parent or guardian of the participant(s) names above, release from responsibility, agree to indemnify and hold harmless the MARJCC, its officers, directors, independent contractors, volunteers and all employees from any illness or injury to me, my child or family members. I hereby give authorization to the MARJCC to secure proper medical treatment from a hospital or physician for my children in the event of an emergency with the cost to be paid by me. I, hereby give permission to the MARJCC and all persons acting with its permission, to obtain, use, copyright and/or publish photo, video, audio maybe used for MARJCC marketing purposes of the above named registrant(s) in whole part in conjunction with the registrant's own name or another name. I hereby grant permission to MARJCC, its Sections, Branches, Institutes, directors, officers, employees or representatives, to take and use photographs, videotape and/or digital images of my child for use in publicity, illustration, publishing (including publishing in electronic form or social media), or other lawful uses as may be determined by MARJCC. I agree that my child’s name and identity: may be revealed in descriptive text or commentary in connection with the use of such image(s). I authorize the use of these images indefinitely without compensation to me. All negatives, positives, prints, digital reproductions and videotape shall be the property of MARJCC. In the event that the MARJCC commences action to recover past due fees, etc. for any program offer by the MARJCC, the MARJCC should be entitled to reasonable attorney's fees and costs. To be eligible for classes and programs, if membership is required, members account must be current and in good standing. If this is not the case, all monies received from the member will first be applied towards membership dues. I CERTIFY THAT I HAVE READ ALL THE ABOVE INFORMATION, PROCEDURES AND POLICIES AND I FULLY UNDERSTAND ITS CONTENT. I understand that by signing this form I agree to follow the above rules, policies and expectations.
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