Want to Request Registration in a LifePlay Class?

Sign Up Your Child Today!!

To request registration in any LifePlay Productions class or event, please complete the short form:

( 1 ) Choose a School & Class...

( 2 ) Tell Us About Your Child...

First Name:		Last Name:
Child's Age:		Gender:	M F
Birthdate:	\	Child's Email:
Any special conditions, behaviors, allergies, or recommendations regarding your child?

( 3 ) How To Contact You...

First Name:		Last Name:
Email:		Phone:
ZIP Code:
	Receive updates about LifePlay classes at my child's school.

( 4 ) Agree to Liability Waiver

Child's Doctor:		Doctor's Phone:
Ins. Carrier:		Policy #:
	Yes, I AGREE to the LifePlay Productions Waiver & Release of Liability below:
	Please Read FULL TEXT of Waiver Agreement... HIDE Full Text of Waiver Agreement... LifePlay Productions Waiver & Release of Liability Agreement PLEASE READ CAREFULLY! In consideration of being allowed to participate in the LifePlay Productions program, I acknowledge and agree that: By participating, my child risks bodily injury including paralysis and death, and/or damage to property. I knowingly and freely assume all such risk for myself and/or child. I understand that LifePlay Productions is not responsible for health injuries to the participants that may arise out of involvement in this program. I release and hold harmless and relinquish attempts at suit against LifePlay Productions, the sponsoring school, partnering agencies, or any of their respective officers, agents or employees with respect to any and all injury, paralysis, death or loss, except for any injury or loss which results from gross negligence or willful or wanton misconduct of one of those individuals or organizations. I am responsible for picking up my child on time at the end of each class. (For your child’s safety LifePlay teachers are paid to remain with the students until all children are picked up. If you are late you are increasing the teacher’s costs for the class.) Based upon the above, I understand that if I am 15 minutes late I will be required to pay $7.50 plus an additional $2.50 cents for every 5 minute increment (or portion thereof) after the initial 15 minutes have pasted. (This is to be paid directly to the teacher at the time of pick up (cash only) and covers their added teaching costs due to your late arrival.) I agree to inform my child that he/she must follow the code of ethics for participants, all safety rules, as well as any others given at the classes. I hereby authorize and give consent for medical care to be given to an emergency situation to my child while he/she is participating in the LifePlay activities. This agreement is binding on my spouse, heirs, next of kin and personal representatives.

( 5 ) [OPTIONAL!] Pay By Credit Card...

You have the OPTION to secure your child's registration with a credit card. (We also gladly accept check by mail.) This is NOT an Online Payment! Once we receive your request, we will contact you by phone or email to confirm your child's registration, and NOT charge your credit card until that time.
Type of Card:		Card Number:
Exp. Date:	\	Name on Card:
Billing Address:
City:		ZIP Code: