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Homework Help Center Registration Form
   

Registration Form

 

 

CHILD'S  NAME :
   
COURSE NAME:
(See above)
   
PARENT NAME:
   
ADDRESS:
   
  TOWN :  ZIP :
   
PHONE:   WORK
   
Grade Success, Inc. Education Center Agreement :
Health Warranty.  I warrant and represent that I have no disability, impairment or ailment that prevents me from engaging in active or passive activities.  This representation is made by me knowing that the Grade Success Education Center will rely upon it in allowing me to participate in educational activities.  Waiver of Claims.  I expressly agree that my use of and / or attendance at the Education Center are undertaken at my sole risk and that the Center’s Owners, managers, employees and agents (Management) shall not be liable for any damages or injuries to me or my property or be subject to any claim, demand, or cause of action, including for any injury or damage resulting from the active or passive negligence of the Education Center, its Management or other Education Center guests.  Release of Education Center. I, on behalf of myself, my executors, administrators, heirs, assigns, and successors, do hereby fully and forever release and discharge the Education Center and its Management from all such claims, demands, injuries, actions or causes of action.  Consent. I consent to pictures being taken of me by the Education Center and understand that such pictures will become the property of the Education Center.  They may be used by the Education Center for promotional purposes without the payment of fees or other compensations to me.  Where a person could or does sign on behalf of his / her minor child (including on a a membership agreement)  the following language also is required.  Where this agreement covers a person who is a minor (under 18 years old) I, as the minor’s parent or legal guardian, expressly make the Healthy Warranty and agree to the Waiver of Claims, Release of Education Center and Consent pro visions contained above. I authorize the Education Center and its Management to obtain medical treatment for my dependent minor.  
 
Signature Parent / Guardian:   Date:
   
Credit Card #    Expiration Date:
   
Staff Initial:   Method of Payment: Amount :
   
Other information regarding services to be provided:

 

**Center may close due to inclement weather. Children must be picked up on time. Education Center staff members are not responsible for children before or after hours.

The Grade Success Education Center in Lifeplex @Sport-O-Rama
   *   18 College Rd   *   Monsey, N.Y. 10952   *   (845) 356-1900 OR (845) 369-7967

 
 
    
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