Parent/Guardian or Center Name *

First Name

Last Name

Phone

(###)

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Emergency contact

First Name

Last Name

Emergency contact Phone

(###)

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Club Preferences *

Select multiple clubs if possible

Academic Clubs

Arts & Creativity Clubs

Life Skills Clubs

Leadership & Culture Clubs

Liability Waiver & Assumption of Risk *

I understand that participation in EPNL Learning Lounge activities may involve minor risks, such as slips, trips, or bumps during play. I accept full responsibility for my family’s participation and agree to release and hold harmless EPNL Learning Lounge, InstaCare Event Center, their staff, partners, and affiliates from liability for any injury, loss, or damages, except in cases of gross negligence.

Parental Supervision Requirement *

I understand that the EPNL Learning Lounge is a shared membership space and not a licensed childcare program.

Parents/guardians must remain with their children at all times.

Parents/guardians are fully responsible for the supervision, care, and behavior of their children while in the lounge.

Staff are present to manage and support the facility but do not provide direct childcare services.

Photo & Video Consent *

I consent to photos or videos of my child(ren) and family being taken during activities for marketing, social media, or promotional purposes.

I do NOT consent to photos or videos of my child(ren) and family being taken during activities for marketing, social media, or promotional purposes.

Medical Consent & Emergency Care *

In the event of a medical emergency, I authorize staff to administer basic first aid and, if necessary, call emergency medical services. I agree to be responsible for any associated medical costs.

Behavior & Code of Conduct *

I agree that my family will:

Treat staff, members, and the facility with respect.

Follow EPNL Learning Lounge rules for safety and fairness.

Use equipment and materials responsibly.

Payment & Refund Policy *

I understand that all membership fees are non-refundable

Monthly memberships will be billed automatically according to the plan selected.

I authorize recurring charges until I cancel my membership in writing, in accordance with the cancellation policy.

Data Privacy *

I understand that all membership fees are non-refundable

I consent to the collection and secure storage of my personal information (such as name, email, and payment details) for membership management purposes. My information will not be sold or shared with third parties except as required by law.

*

I understand that the Learning Lounge allows up to 20 children per session, and I agree to supervise my child(ren) and follow all lounge safety rules and policies.