AFTERSCHOOL REGISTRATION WINTER/SPRING 2021

AFTERSCHOOL WINTER/SPRING 2021 REGISTRATION

CHILD'S NAME & PREFERRED PRONOUNS

First & Last

AGE & GRADE

DATE OF BIRTH

SCHOOL

Are you registering a sibling?

Yes

If you are registering a sibling , make sure to fill out another application for the sibling. You will be directed to payment after each application.

If yes, what is the name of the sibling?

ALLERGIES / DIETARY LIMITATIONS / PHYSICAL OR DEVELOPMENTAL CONCERNS * (If your child does have any specific developmental concerns, please include stress triggers as well as effective behavioral strategies)

DOCTOR'S NAME AND NUMBER

PARENT/GUARDIAN NAME

Address

PHONE NUMBER

PARENT/GUARDIAN NAME - 2

ADDRESS

PHONE NUMBER

EMERGENCY CONTACTS - PLEASE LIST NAME, EMAIL AND PHONE NUMBER OF 3 EMERGENCY CONTACTS:

PLEASE LIST ALL ADULTS ALLOWED TO PICK UP YOUR CHILD/CHILDREN FROM OUR AFTER-SCHOOL PROGRAM

PLEASE LIST ANY PERSONS NOT PERMITTED TO PICK UP YOUR CHILD/CHILDREN FROM OUR AFTER-SCHOOL PROGRAM

SCHEDULE (please choose all classes you are registering for):

MONDAYS

3PM IN-PERSON URBAN NATURALIST | K-5 GRADES

WEDNESDAYS

3:00PM IN-PERSON CHANGEMAKERS CLUB | K-5 GRADES

4:00PM IN-PERSON YOGA | K-3 GRADES

LIABILITY WAIVER (Please Read Carefully)

I individually and as parent and/or guardian of the minor child/children identified in this form hereby acknowledge the following notices and grant Bodhiananda Wellness, dba Bread and Yoga the following release from liability: A. I acknowledge and fully understand that my child will be engaging in physical activities that may involve some risk of injury. I acknowledge and have been advised that it is my responsibility to consult with my or my child’s physician with respect to any past or present injury, illness, health problem or any other condition or medication that may affect my or my child’s participation. I assume the foregoing risks and accept full personal responsibility for any personal injuries sustained by my child which might incur as a result or participating in this program and discharge and hold harmless Bread and Yoga, their owners, directors, members, employees and agents from any claim, cause of action or liability for damages arising from any personal injury to my child or other persons or property caused by myself or my child’s participation in the Bread and Yoga program. B. The undersigned ("We") agree for themselves and for the student to pay Bread and Yoga the correct fee for the SEMESTER registered at our after-school program. Full payment is required with this application. This registration becomes effective only upon receipt and acceptance of the payment and registration form. Failure to comply with the terms of this agreement will subject you to cancellation at anytime, including during the Bread and Yoga's program session. All bills are due when rendered. Bread and Yoga retains the right to charge 1.5% per month (equal to 18% per year) to all late payments. PLEASE NOTE THAT WE DO NOT ACCEPT MONTH-TO-MONTH REGISTRATIONS. In the event of you choosing to cancel or reduce the amount of days your child attends after-school, you are still responsible for paying the full tuition costs. FULL REFUNDS WILL BE GIVEN UP TO ONE WEEK BEFORE THE START OF THE PROGRAM, OR IF REGISTRATION IS CANCELLED BY BREAD AND YOGA. IF YOU REQUEST A REFUND LESS THAN ONE WEEK BEFORE THE START OF THE PROGRAM BUT BEFORE THE PROGRAM BEGINS, BREAD AND YOGA WILL RETAIN A $50 PROCESSING FEE. CANCELLATIONS AFTER THE START OF THE PROGRAM SHOULD BE DONE IN WRITING WITH 30 DAYS NOTICE. IF YOU WOULD LIKE TO SWITCH CLASSES OR DAYS THROUGHOUT THE SESSION, REQUESTS MUST BE SUBMITTED IN WRITING AND WE WILL HONOR THESE REQUESTS BASED ON SPACE AVAILABILITY IN THE DESIRED CLASSES/DAYS. WE SUBMIT TO THE JURISDICTION OF THE STATE OF NEW YORK WITH RESPECT TO ANY DISPUTES REGARDING THIS CONTRACT AND/OR BREAD AND YOGA. FURTHER IF THERE IS A DISPUTE, THEN THE PREVAILING PARTY IN THE DISPUTE SHALL BE ENTITLED TO RECOVER THE COSTS AND FEES (INCLUDING REASONABLE ATTORNEY FEES) INCURRED IN CONNECTION WITH THE DISPUTE. *

By initialing the PARENTAL/GUARDIAN SIGNATURE ACKNOWLEDGEMENT AND AGREEMENT box and submitting this form, I agree to the terms and conditions listed above.

ACTIVITY CONSENT FORM AND APPROVAL BY PARENT OR LEGAL GUARDIAN

My Child has approval to participate in ALL WALKING TRIPS INCLUDING ISHAM PARK, INWOOD HILL PARK, NORTH COVE, ETC. Date(s) of outings: 4/2021-6/2021 Departure Site: Isham Park. Departure Time: BETWEEN 3:00PM-5:00PM Return Site: Isham Park or Inwood Hill park Return Time: BETWEEN 3:30PM-6PM *

PARENT/GUARDIAN SIGNATURE ACKNOWLEDGEMENT AND AGREEMENT

By checking the PARENTAL/GUARDIAN SIGNATURE ACKNOWLEDGEMENT AND AGREEMENT box and submitting this form, I agree to the terms and conditions listed above.

COVID-19 WAIVER: HOLD HARMLESS AGREEMENT

I acknowledge that the novel coronavirus ("COVID-19") infections have been confirmed throughout the United States, including New York City, and understand the hazards associated with COVID-19 and the guidance and protocols issued by federal, state, and local governments and federal and state health agencies for slowing the transmission of COVID-19. I acknowledge the risks associated with COVID-19, and hereby willingly choose to allow my child to participate in one or more of the Bread & Yoga after-school programs. Bread & Yoga has put in place protective measures to reduce the spread of COVID-19; however, Bread & Yoga cannot guarantee that Myself or my child(ren) will not become infected with COVID-19. I fully acknowledge both the known and potential dangers of participating in the program and acknowledge that such participation may, despite Bread & Yoga’s reasonable efforts to mitigate such dangers, result in exposure to COVID-19, which could result in quarantine requirements, serious illness, disability, and/or death. I have carefully considered the risk involved and have given consent for my child to participate in the activity. I understand that participation in the activity is entirely voluntary and requires participants to abide by all applicable rules and standards of conduct, including but not limited to all company policies, guidelines, signage and instructions. To prevent the spread of COVID-19 and reduce the potential risk of exposure to all parties, I also understand that I will be required to complete a simple screening questionnaire prior to my child’s arrival each day. I release BREAD AND YOGA, the activity coordinator, and all employees, volunteers, related parties, or other organizations associated with the activity from any and all claims or liability arising out of this participation. In case of emergency involving my child, I understand every effort will be made to contact me. In the event I cannot be reached, I hereby give my permission to the medical provider selected by the adult leader in charge to secure proper treatment, including hospitalization, anesthesia, surgery, or injections of medication for my child. Medical providers are authorized to disclose to the adult in charge examination ﬁndings, test results, and treatment provided for purposes of medical evaluation of the participant, follow-up and communication with the participant’s parents or guardian, and/or determination of the participant’s ability to continue in the program activities. *

PARENT/GUARDIAN SIGNATURE ACKNOWLEDGEMENT AND AGREEMENT

By checking the PARENTAL/GUARDIAN SIGNATURE ACKNOWLEDGEMENT AND AGREEMENT box and submitting this form, I agree to the terms and conditions listed above.

YOUTH PROGRAMS FOR MINORS MEDIA, PHOTO, & VIDEO RELEASE FORM (Please read the following release carefully and sign below.)

As to any child/children who are enrolled in the after-school program operated by the Studio, I agree that Bread & Yoga (including its staff, employees and agents) can take and use photos, video and audio recordings of the child/children named in this registration for the limited purposes of providing content for the AfterSchool blog and/or marketing the program which may be publicly available on the internet, without compensational obligation, and I hereby release the Studio (including its staff, employees and agents) from any claims resulting from their use of photos, videos and audio recordings (Please note: if you want to understand why we seek your consent for this or to request that we do not publicly use photos, videos and/or audio recordings featuring your child/children, please contact director@breadandyoga.com ). Further, I acknowledge and agree that the child/children and myself and any co-parent or co-guardian, are not allowed to take, and shall not take, any photographs, video, or other recordings of other children or other parents/guardians participating in the programs without their express consent, and are not allowed to transmit, upload, or post such content online or electronically including on any social media or similar site, or use or publish such content in any non-personal media such as a book, video, film, television program or publicly viewable website. Upon the Studio’s request, I agree to delete and/or remove such content from any device, site, platform, or other media, if, in the Studio’s sole and absolute discretion, such content and/or the manner in which it is presented violates the terms of this agreement, is objectionable, inappropriate, or violates the privacy rights or right of publicity of others. *

PARENT/GUARDIAN SIGNATURE ACKNOWLEDGEMENT AND AGREEMENT

By checking the PARENTAL/GUARDIAN SIGNATURE ACKNOWLEDGEMENT AND AGREEMENT box and submitting this form, I agree to the terms and conditions listed above.

COPPA NOTIFICATION

Parental Notice Regarding the Children’s Online Privacy Protection Act (“COPPA”) Under the Children’s Online Privacy Protection Act (“COPPA”), we must provide you with direct notice before collecting “personal information” from your child. Effective July 1, 2013, the Federal Trade Commission (“FTC”) updated COPPA to reflect changes in technology, and now considers a photograph, video, or audio file containing a child’s image or voice to be a child’s “personal information.” For more information about COPPA, please visit https://www.consumer.ftc.gov/articles/0031-protecting-your-childs-privacy-online. By participating in an event and/or registering your child for the programs operated by Bread & Yoga, your child will have the opportunity to participate in our various online and/or in-person activities. In some of the activities, your child may participate in online video sessions and/or use online applications to create photo, video, or audio files, projects or software applications that may contain your child’s image or voice as well as the image or voice of other children participating in the program. Once your child has participated in an online session or completed a project, those video or audio files or projects may be shared with participants and their families. Your consent is required for the collection, use, or disclosure of your child’s information as may appear in a photo, video, or audio file, or project(s) or software application that your child creates, collaborates on, participates in, or was included in as part of the after-school activities. Your consent authorizes the collection, use, or disclosure of your child’s information as may appear in a photo, video, or audio file or project(s), or software application to children, parents/guardians of children and staff members of Bread & Yoga as well as to third parties who may receive your child’s information from other children or parents/guardians whose children attend the same online session and/or collaborate on, participate in, or were included in projects with your child. We will not collect, use, or disclose any such information from your child if you do not consent. If you do not provide consent to the collection of your child’s personal information as described above, your child will not be able to register or participate in some activities offered by Bread & Yoga, including the Good News Crew. At any time, you may refuse to permit: 1) your child’s participation in Bread & Yoga (including events, online sessions and/or the after-school activities); 2) further use of your information or your child’s information by Bread & Yoga; or 3) further contact with your child, and request that we delete your information and/or your child’s information. To exercise any of your rights, please email us at director@breadandyoga.com. Your privacy and your child’s privacy are important to us. We do not share any of your information or your child’s information with any third party, except in the limited fashion described above whereby your child participated in an online session and/or collaborated on, participated in, or was included in a project. CHANGES IN THIS COPPA STATEMENT We may change this COPPA Notice. If we decide to change our COPPA notice, YOu will be notified directly. We reserve the right to modify this privacy statement at any time. *

PARENT/GUARDIAN SIGNATURE ACKNOWLEDGEMENT AND AGREEMENT

By checking the PARENTAL/GUARDIAN SIGNATURE ACKNOWLEDGEMENT AND AGREEMENT box and submitting this form, I agree to the terms and conditions listed above.

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AFTERSCHOOL REGISTRATION WINTER/SPRING 2021

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