Member Enrollment Contract 18-19
Please complete this online form so that we can collect important demographic and enrollment contract information electronically. All responses are private. There are no refunds for any portion of the fees for the services you select in this contract. Note: Children over 12 months but younger than 24 months will be charged the $50 member fee and should be added as a participant here (Member Only). Children who age into a new price tier for any program will be prorated at their birth month.

You must pay a deposit to secure your enrollment. You will pay the Member Fee plus $200 per program selected immediately as a deposit. All deposits are due immeidately. You may also request a payment plan on this form to defer payments beyond July 2018. If at any time to cease to participate in your selected program(s), your balance will be due in full at that time.
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Primary Parent Name *
Primary Parent Phone *
Please provide both home and cell phone numbers.
Family Address *
Please provide actual and mailing
Parent or Helper Contact Info *
Please provide all email addresses that may be associated with the adults who bring or pick up your children. List name then email and cell phone number.
Please list all children enrolled, their age, and DOB. *
Please provide an emergency contact for both parent and children enrolled. *
This contact must not be a parent or helper who regularly attends WGC.
Do you require a payment contract? *
Note: You will be charged a $50 fee to create a loan agreement as your payment plan. If you repay your loan in full with all payments on time before the final due date, that fee will be discounted from your final payment. Please look for an email with directions to complete your payment plan loan agreement. We have moved to an online process for this.
By enrolling in Walnut Grove Coop, you agree to allow your contact information to be shared within the group for the purposes of administering activities. *
Required
Walnut Grove Coop respects member allergies. By enrolling in Walnut Grove Coop, you agree to respect these restrictions. If your family has any severe allergy that may require medical intervention, you agree to report those allergens to staff. *
Required
Please report any allergens that your family may need to avoid. Please note that dietary restrictions are not considered "allergens" but will be respected though not prohibited.
Please report any medications that your child regularly receives and for what reason. List Child's name, Medication name, and Reason below.
Please note any side effects experienced by your child so that our staff may be sensitive to them.
Walnut Grove Coop is a member based club. A membership fee is assessed for each child but accompanying adults are free. A member may take classes and participate in all programs. Adult members are liable for all expenses for classes or programs for which they enroll and register their children. *
Required
By enrolling in Walnut Grove Coop, you understand that no refunds are issued for leaving the group. If at anytime you cease to desire to participate you may leave but will be obligated to immediately pay any balance due upon leaving for all services for the entire term for which you have children enrolled. Services from Walnut Grove Coop will cease immediately if you choose to leave the program. *
Required
By enrolling in Walnut Grove Coop, you understand that you are soley liable for the actions of your child. Walnut Grove Coop, its parents, its child members, and its affliliates such as but not limited to instructors and the Newark Church of Christ (building used) are not legally or financially responsible for any injury to members or property. If your enrolled child(ren) cause harm to persons or property you will be legally and financially liable. *
Required
As a member of Walnut Grove Coop you are entitled to express concerns or grievances about other members or programs to the group lead (Melissa Layfield). All complaints and concerns will be documented and handled with privacy and all diplomacy possible. *
Required
All members are expected to treat all other members with respect. Members agree to respect each other, staff, and property. Violence or other abusive behavior toward children from adults is strictly prohibited and is cause for immediate removal from this group. While we all employ different parenting styles, physical punishment or screaming to reprimand children is strictly prohibited. *
Required
Walnut Grove Coop is a member cooperative and expects parent/helper contribution as part of membership. Any parent who fails to generally contribute to the activities within the Coop membership may be asked to leave the club. All members will be given one written warning. Continued failure to contribute will result in removal from this group. *
Required
Walnut Grove Coop may take photographs or video of members participating in group activities. These images or sounds may be used promotionally. Walnut Grove Coop respects member privacy and will omit a child's likeness from publications or the internet, when requested to do so by the parent. *
Required
Please check all programs for which you are registering. If you are registering more than one child, please note the child's name in the "other field" and complete this question again for your next child.
SECOND CHILD - Please check all programs for which you are registering. If you are registering more than one child, please note the child's name in the "other field" and complete this question again for your next child.
Third CHILD - Please check all programs for which you are registering. If you are registering more than one child, please note the child's name in the "other field" and complete this question again for your next child.
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