Class: Upper West Side - Thursdays - 3:30 PM 4:15 PM 4/19/2012 to 6/21/2012 - For Ages 3-4 Please make checks payable to LIL' RUGGERS and mail to: LIL' RUGGERS Attn: Dev Brumberger 115 East 72nd St. #4B New York, NY 10021 NOTE: Your child's spot in the class will only be confirmed upon receipt of payment Child's First Name(required) Child's Last Name(required) Date of Birth(required) Gender M F School(required) Address(required) City(required) State(required) Zip(required) Parent's Name(required) Email(valid email required) Telephone(required) PARENTAL/GUARDIAN AGREEMENT AND MEDICAL RELEASE I give permission for my child to fully participate in the LIL’ RUGGERS program (the “program”). As a condition to my child’s participation in the program, I hereby agree as follows: I am the parent or a legal guardian of the child enrolling in this program. I recognize that participation will involve physical activities and exertion, which may result in physical injury, and I do hereby acknowledge that I am aware of this, and I voluntarily elect for my child to participate. I certify that my child is in good health and that s/he has no special medical or physical conditions that would impede or prevent his/her participation in the program. I further agree that the decision as to my child’s physical fitness to participate in the program is my responsibility alone, and LIL’ RUGGERS shall bear no responsibility for my decision to allow my child to participate. I understand that in the event of injury or illness to my child, LIL’ RUGGERS will attempt to contact me at the contact numbers provided. In the event they cannot reach me, I hereby authorize the medical personnel selected by LIL’ RUGGERS to secure proper treatment for, and to authorize any necessary medical procedures at my cost and expense. I accept and assume responsibility for any risks, injuries or damages, foreseeable or unforeseeable, which my child might incur or suffer as a result of participating. To the fullest extent under the law, I hereby knowingly, voluntarily and expressly waive and release LIL’ RUGGERS, its respective officers, directors, agents, representatives, employees, successors, assignees, and licensees (hereinafter, "the Released Parties"), from any and all claims, actions, damages, losses, liabilities, costs and expenses of any kind whatsoever, including but not limited to any claims of negligence, arising out of, resulting from, by reason of, or in connection with my child's participation in any LIL’ RUGGERS program or activity. I agree that I will not bring or be a party to any legal action or claim against the Released Parties, or any of them, based upon or arising out of my child's participation in any LIL’ RUGGERS program or activity on any legal theory whatsoever (including without limitation personal injury, negligence, rights of privacy and publicity, or defamation). I understand and agree that LIL’ RUGGERS, in its sole discretion, has the right to terminate the enrollment of my child if it determines that continued attendance in the program is not in the best interest of the child nor the program. I agree to supervise or designate a responsible adult to supervise my child prior to and immediately after his/her program activities. Media Release: LIL’ RUGGERS and its agents reserve the right to take and utilize photographs, video, or any type of recording of participating children and their parents, caregivers, or anyone accompanying them to LIL’ RUGGERS while engaged in our classes or associated activities. I consent to LIL’ RUGGERS’ use of the photograph, video, or recording of my child, me, or the guardian I have designated for advertising, promotional, and/or related purposes, and waive all rights to compensation and other rights which may arise as a result (including any rights under N.Y. Civil Rights Law 50). Weather Policy and Make-Ups: LIL’ RUGGERS will make every effort to determine whether or not to cancel class due to inclement weather no later than one hour before the scheduled start time of the class, based on available hourly forecasts. In most cases, drizzle or light rain do not constitute cause for cancellation. There is one extended week at the end of scheduled classes for classes canceled due to inclement weather. If more than one class per season is cancelled due to extreme forecasts, credit will be offered toward the upcoming season. If your child misses a class, s/he may make it up in another class by calling the office and scheduling the makeup. You are allowed one make-up class per season. Payment & Refunds: Should you need to withdraw your child, LIL’ RUGGERS offers a pro-rated refund (minus a $40 administrative/Jersey fee) for the session’s remaining classes before the fourth class of any period. There are no refunds thereafter. In the event that you decide to withdraw your child from the program, you must notify the LIL’ RUGGERS office no less than 24 hours before the fourth class of the pertinent period, and are responsible for all charges until you do so. There are no refunds for missed classes. We reserve the right to cancel classes due to low enrollment. At least 6 children are needed to have a class. Your child's spot will not be confirmed in the class until payment and application are received. Appropriate Attire: Children MUST wear sneakers (closed toe with laces or Velcro) or they will not be allowed to participate in class. Sweatpants or shorts are recommended. LIL’ RUGGERS is not responsible for your personal belongings; please keep your items with you at all times. LIL’ RUGGERS will provide a long sleeve rugby jersey for each child, and we ask that all children wear them to class. Children who wear glasses must use shatterproof eyewear at all times. Extra jerseys are available ($40 each). Mini Rugby balls are also available ($10 each). Toys/Food: There are absolutely no toys or snacks allowed out of their containers during class. All administrative questions must be referred to the office, not to the coaches. By checking in the box, I state that i have read the above release and waiver of liability and fully understand its contents. I voluntarily agree to the terms and conditions stated above. Note: If the class is cancelled because of under-enrollment, you will be notified and refunded within 30 days.