Register Now | Leaps N Boundz

Prior to your child’s initial evaluation, he/she must be fully registered online. If your child is not registered, we cannot allow him/her to participate due to safety and liability issues.

Family Name

Please note that the student's last name must be listed in the family last name slot, even if the parent's last name is different.

Address *

City *

State *

ZIP Code

Contact #1

First Name *

Last Name *

Relationship to Student *

Home Phone (###) ###-####

Mobile Phone (###) ###-####

Work Phone (###) ###-####

Email Address *

Contact #2

First Name

Last Name

Relationship to Student

Home Phone (###) ###-####

Mobile Phone (###) ###-####

Work Phone (###) ###-####

Email Address

Email addresses are kept confidential

Emergency Contact

First Name

Last Name

Contact Phone (###) ###-####

Student Information

Complete Student Information for each child that will be participating.

Student #1

First Name *

Last Name *

Email Address

Gender

Birthdate *

Month

Day

Year

School

Grade Level

Disabilities

Allergies

Medications

Primary Doctor

Student #2

First Name

Last Name

Email Address

Gender

Birthdate

Month

Day

Year

School

Grade Level

Disabilities

Allergies

Medications

Primary Doctor

Student #3

First Name

Last Name

Email Address

Gender

Birthdate

Month

Day

Year

School

Grade Level

Disabilities

Allergies

Medications

Primary Doctor

Student #4

First Name

Last Name

Email Address

Gender

Birthdate

Month

Day

Year

School

Grade Level

Disabilities

Allergies

Medications

Primary Doctor

Student #5

First Name

Last Name

Email Address

Gender

Birthdate

Month

Day

Year

School

Grade Level

Disabilities

Allergies

Medications

Primary Doctor

Terms and Conditions

Release of Liability *

As the legal parent or guardian, I release and hold harmless Leaps-n-Boundz its owners and operators from any and all liability, claims, demands, and causes of action whatsoever, arising out of or related to any loss, damage, or injury, including death, that may be sustained by the participant and/or the undersigned, while in or upon the premises or any premises under the control and supervision of Leaps-n-Boundz, its owners and operators or in route to or from any of said premises.

Medical Emergency *

I have read and agreed to the following statement.

The undersigned gives permission to Leaps-n-Boundz, its owners and operators to seek medical treatment for the participant in the event they are not able to reach a parent or guardian. I hereby declare any physical/mental problems, restrictions, or condition and/or declare the paricipant to be in good physical and mental health.

Payment Information *

I have read and agree to the following statement.

Tuition is due by the 15th of each month. If accounts are paid after the 15th of the month, there will be a $15.00 late fee applied to the account balance. There is a $20.00 returned check charge for any checks returned by the bank.

Signature Text *

I have read and agree to the following statement.

As the legal parent or guardian, I the undersigned give permission to Leaps-n-Boundz, its owners and operators to take photographs during sessions. With permission given (by the legal parent or guardian), these photographs may be used for publication. I have read and understand the policies and procedures of Leaps-n-Boundz as stated in the Parent Handbook.

Full Name *

Additional Comments