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REGISTRATION

Summer Program Registration Overview
June 10th - July 26th, 2024

Enrollment is open to any child from ages 5 - 15. Registration is not complete until after the registration
packet has been completed and returned with registration fee.

HOURS
9:00 AM until 5:00 PM Monday - Friday excluding: June 19th, July 4th, July 10th - 12th.

Breakfast is from 9:00am - 9:30am; Snack is from 11:30 - 11:45; Lunch is from 12:45 - 2:15 (groups
pending)

Contact the front office of The Academy of Excellence for more information on daily activities, field
trips, enrichment and more. You may visit WEST JACKSONVILLE RESTORATION CENTER 9am - 5pm daily.

*Late pick up fee is $1 per minute, per child, for any child picked up later than 5pm. The fee is
due in cash only at pickup and must be paid before the child may attend the program again.
Habitual offense for late pick ups will result in your child being dismissed from the program.

Phone

904-779-0177

Email

CHILD INFORMATION *Child must be 6 - 15 years old and have a duval address for registration*

Gender

PARENT/GUARDIAN INFORMATION

EMERGENCY CONTACTS & AUTHORIZED TO PICK UP

ID IS REQUIRED TO PICK UP YOUR CHILD (REQUIRED: MINIMUM OF 2 OTHER THAN PARENTS)

Medical Information

PLEASE INDICATE ANY OF THE FOLLOWING:

SPECIAL NEEDS

PLEASE HELP US LEARN ABOUT YOUR CHILD’S SPECIFIC SPECIAL NEED AND ABOUT HIS/HER ABILITY TO MANAGE EVERYDAY
TASKS THAT ARE COMMON IN OUR PROGRAM. BEFORE YOUR CHILD IS ENROLLED, WE WILL MEET WITH YOU TO DISCUSS
FURTHER.

ADDITIONAL INFORMATION

REGISTRATION FORM | June 10th - July 26th, 2024
West Jacksonville Restoration Center| 904.779-0177 ext. 3|

A completed registration consists of a completed Registration Packet (Child Information Form, Medical Information, a
signed copy of Conditions of the WJRC After School Program, and a signed copy of all required waivers). Your child may
not attend WJRC After School Program until ALL required forms are completed and on file with the WJRC. After School
program.

CONDITIONS OF THE WJRC SUMMER Program
While the WJRC Summer Program will make every attempt to provide reasonable accommodations for
mentally and physically challenged children, WJRC will not accept children that are (1) a danger to
themselves, (2) a danger to others, or (3) a disruption to the normal activities making it unreasonably
difficult for other children to enjoy any special conditions or circumstances involving your child. The WJRC
Summer Program strongly recommends that you discuss with the WJRC staff any special conditions or
circumstances involving your child. WJRC requests that the undersigned do this PRIOR to registration so
that WJRC can advise as to whether we can make reasonable accommodations for your child.
The undersigned understands that West Jacksonville Restoration Center (WJRC) is NOT responsible for any
personal property lost or stolen while members and/or program participants are using WJRC facilities or
are on any WJRC premises.
I give my permission to WJRC to use, without limitations or obligations, photographs, film footage or tape
recordings that may include mine and or my family member’s image(s) or voice(s) for purposes of
promoting or interpreting WJRC programs.
The undersigned hereby gives his or her permission to the physician selected by WJRC to hospitalize,
secure proper treatment for, and to order injections, anesthesia or surgery for the individual named on
this application in the event my designated emergency contact person cannot be reached.
The undersigned understands that no accident or medical insurance is provided for WJRC participants.
The undersigned gives his or her permission for my child to be transported by the bus service secured by
WJRC for program related activities.
CHILDREN MUST BE PICKED UP NO LATER THAN 6:00 PM OR A LATE CHARGE OF $1.00 PER
MINUTE, PER CHILD WILL BE CHARGED AND IS DUE AT THE TIME THE CHILD IS PICKED UP OR
BEFORE THE CHILD RETURNS TO PROGRAM.


ACCEPTANCE
I accept the conditions of the WJRC Summer Program set forth above and, being in sympathy with the
Mission of West Jacksonville Restoration Center, hereby apply to participate.

ONLY THE INDIVIDUAL WHOSE SIGNATURE APPEARS ON THE ORIGINAL REGISTRATION FORM IS
AUTHORIZED TO MAKE CHANGES TO THE REGISTRATION FORM, INCLUDING ADDING, DELETING, OR
TEMPORARILY DESIGNATING INDIVIDUALS AUTHORIZED TO PICK UP CHILD.

FLORIDA MINOR RELEASE AND WAIVER OF LEGAL LIABILITY
THIS IS YOUR RELEASE AND WAIVER OF LIABILITY

 

(the “Release”). You individually and on behalf of your
minor child, release West Jacksonville Restoration Center (WJRC), its officers, directors, board members,

employees, volunteers, agents, independent contractors, and other participants and/or others acting on its
behalf (collectively. “WJRC”). You agree this Release is effective immediately.


NOTICE TO THE MINOR CHILD’S NATURAL GUARDIAN
READ THIS FORM COMPLETELY AND CAREFULLY. YOU ARE AGREEING TO LET YOUR MINOR
CHILD ENGAGE IN A POTENTIALLY DANGEROUS ACTIVITY. YOU ARE AGREEING THAT, EVEN IF
WJRC USES REASONABLE CARE IN PROVIDING THIS ACTIVITY, THERE IS A CHANCE YOUR
CHILD MAY BE SERIOUSLY INJURED OR KILLED BY PARTICIPATING IN THIS ACTIVITY
BECAUSE THERE ARE CERTAIN DANGERS INHERENT TO THE ACTIVITY WHICH CANNOT BE
AVOIDED OR ELIMINATED.
BY SIGNING THIS FORM YOU ARE GIVING UP YOUR CHILD’S RIGHT AND YOUR RIGHT TO
RECOVER FROM WJRC IN LAWSUIT FOR ANY PERSONAL INJURY, INCLUDING DEATH, TO YOUR
CHILD OR ANY PROPERTY DAMAGE THAT RESULTS FROM THE RISKS THAT ARE A NATURAL
PART OF THE ACTIVITY. YOU HAVE THE RIGHT TO REFUSE TO SIGN THIS FORM, AND WJRC HAS
THE RIGHT TO REFUSE TO LET YOUR CHILD PARTICIPATE IF YOU DO NOT SIGN THIS FORM.
I HAVE READ AND AGREE THE ABOVE WAIVER, RELEASE, AND INDEMNIFICATION AGREEMENT:

Thanks for submitting!

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