4th & 5th Grade Game Time Please enable JavaScript in your browser to complete this form.Come hang out upstairs on Wednesdays. Drop in anytime between 2:30-5:30pm. Snacks and games provided!Participant Name *FirstLastAge *Date of Birth *Contact InformationName of Parent/Guardian *FirstLastWhat is your relationship to the participant? *Phone *Email *Physical Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeOn-Island Emergency Contact *FirstLastEmergency Contact Phone *What is your child's end-of-day plan? If applicable, please provide names of people allowed to pick-up your child from The Funhouse. *Payment MethodStripePayPalA drop-in fee of $5 per day or $20 per month is suggested. If choosing PayPal, you will be redirected to the PayPal site after clicking Submit at the bottom of the form.Payment AmountPlease enter your payment information:CardName on CardDo you need a scholarship to help pay for this program?YesNoIf yes, you will be contacted by Sarah McKay to discuss your needs and how The Funhouse can support you. By signing this form, I declare that I am the legal parent/guardian of the minor child(ren) listed above and am authorized to grant such permission. I agree to hold harmless the Funhouse, its employees, volunteers, or anyone connected with the Funhouse organization for any injury or other problems arising from participation in this program. *I AgreeBy signing this form, I understand and agree that photographs/videos taken of my child(ren) at The Funhouse Commons may be used by The Funhouse Commons for promoting our programs, classes, events, in print, TV, social media or on the website. *I AgreeI Do Not AgreeParent Signature *Clear SignatureSubmit