PRESCHOOL/TOT or SOCIAL PARTICIPANT
2014
Sarah Heinz House “Signature” Form
2015
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HERE
**PLEASE PRINT AND SIGN CLEARLY**
This document is used AFTER a parent or guardian completes the ONLINE PRE-REGISTRATION process on a
computer, and they come in person to Heinz House for to complete the registration process, payment for classes.
If you have not submitted the pre-registration information, you must do that first on a computer. The link is on our website at
www.sarahheinzhouse.org.
****If information changes from the online application or this signature form during the year,
please notify us so we can best serve your child.****
General Information
Participant’s Name: (First, Middle Last,)
Birthdate:
Gender:  Male
Home Phone Number:
Parent Cell:
Age as of today:
 Female
Primary Contact (Full Name):
Relationship to
Participant:
Member Cell:
Any information about the child or family that might help staff and volunteers to work better with the child, but you
were we were unable to write about through the computer pre-registration process?
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
PARENT: Please place your initials beside each of the statements below to verify that
you understand and agree to each one.
_____ When I completed the PRE-REGISTRATION process, I understood that children AND parents are
responsible for knowing the rules and regulations of participation at Sarah Heinz House.
_____ I understand that parents are permitted in the Great Hall and Cafe' areas only, unless they are actively
participating in one of the tot or preschool classes (for example: swimming lessons, tot gymnastics, etc.)
_____ I understand that my child is a “participant”, not a youth "member" of Sarah Heinz House (actual
youth membership is for children in 1st through 12th grades) , and does not have the privileges associated
with youth membership, except for participation in this program.
_____ I understand that during my child's participation in his/her program, a parent or caregiver of the child
must remain in the building.
_____ I understand that participation in a program at Sarah Heinz House is a privilege, and can be revoked
(with no refund) for incidents regarding poor behavior or poor attendance.
Please complete BOTH sides; continued on BACK…
Preschool/Tot/Social Participant Signature form, page 2 of 2
_____ I agree that my child’s photograph (likeness), if it should appear in any form of media coverage or
promotional brochures of Sarah Heinz House, may be used without any further authorization or any
reimbursement to my child or me from Heinz House.
_____ I understand that staff are trained in and provide only Basic First Aid and CPR. It is the parent’s
responsibility to arrange and implement any medical treatment or care beyond basic first aid.
_____ I understand that “make up classes” are not offered if a class is cancelled due to weather or other
unforeseen circumstances. Specific number of classes is not guaranteed. Classes are offered at the scheduled
times during each trimester when Heinz House is open for normal programming. Scheduled exceptions to
normal programming are listed in the Preschool & Tot Program Booklet, and monthly Bulletin (for example,
no classes are offered during the week of Thanksgiving).
_____I understand, acknowledge and agree to waive, release and discharge Sarah Heinz House, and all those
affiliated with the organization, from any and all claims of liabilities for harm, personal injuries or damages of
any kind, which arise out of or relate to the above named child’s participation in programs and activities. I
also expressly release and discharge Sarah Heinz House, and those affiliated with the organization, from any
liabilities or claims associated with the rendering of, or failure to render, any type of emergency, medical
and/or first-aid services. I further agree to indemnify and hold Sarah Heinz House harmless for any harm,
injury or property damage resulting from or arising out of the above named child’s actions.
*** No refunds are given to individuals who withdraw or are suspended from their class(s), because of
their choice, or because of attendance or behavior.
Do you agree to this?  Yes
 No
Disagreement with any of the above policies must be presented in writing, to Sarah Heinz House staff, and
may result in declined participation.
By signing below, I (we) are stating that we understand and we agree to the policies and guidelines listed
above. (NOTE: Parent is signing on behalf of ALL family members; Parent signature required for
processing).
Parent/Guardian Name:
_______________________
Parent/Guardian Signature:
_______________________
END of APPLICATION / Signature Form
---------------------------------------------------------------Add’l Staff Notes:
2014-15 preschool signature form