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| CHARLIE'S PLACE REGISTRATION FORM (PART TWO) We offer a variety of activities/programs at Charlie's Place and we recognize the fact that not every activity/ program is acceptable to every parent/guardian. Therefore, we would like to offer you the opportunity to inform us as to what you do not approve of for your child. If you DO NOT wish your child(ren) to participate in any of the activities/programs lsited below, please check the line next to the activity/program that you DO NOT want your child(ren) to be involved with and we will make sure that your child(ren) DOES NOT participate. If you do not check the line or if you do not send this paper back to us, we will operate under the assumption that it is okay for your child(ren) to participate in all of the activities/programs listed below. Thank you! PLEASE ONLY CHECK THE LINES NEXT TO THOSE ACTIVITIES YOU DO NOT APPROVE OF FOR YOUR CHILD(REN)!!!! IF YOU HAVE MORE THAN 1 CHILD REGISTERED HERE, PLEASE WRITE THE NAMES OF ALL THE CHILDREN THAT THE FOLLOWING APPLIES TO. My Child(ren)________________________________________________________________________________ should NOT participate in the following: _____ Watching movies (Rated PG-13 or below; screened for inappropriate language/content) _____ Eating free snacks (granola bars, rice krispie treats, cereal bars, carrot sticks, fresh fruit, etc.) _____ Eating dinner (Similar to school lunches but made with low-fat healthy ingredients) _____ Using points to obtain snacks or drinks (Gatorade, Juicy Juice, Trident Gum, crackers, fruit snacks, etc) _____ Downloading music from the Internet and burning CDs (music is screened and only the edited/cleaned versions of songs may be downloaded -- kids can use their points to 'purchase' CDs) _____ Using the Internet _____ Using Instant Messengers on the computers _____ Other (Please be as specific as possible) ___________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ Parent/Guardian Signature__________________________________________________ Date______________ -------------------------------------------------------------------------------------------------------------------------------- As you may already know, our stated policy for dealing with children who disrupt Charlie's Place or who refuse to follow the rules is to give out warnings. After a certain number of warnings (the number depends on the offense in question) we will ask the child who has been warned to leave the Charlie's Place premises. If you wish us to make other arrangements for your child in the event of a temporary or permanent expulsion, please tell us below how you would like us to handle such a situation and send this paper back to us. If we do not receive this paper, we will operate under the assumption that asking your child to leave the premises is acceptable to you. IF YOU HAVE MORE THAN 1 CHILD, PLEASE WRITE THE NAMES OF ALL THE CHILDREN THAT THE FOLLOWING APPLIES TO. _____ Please ask my child to call me or an emergency contact person before leaving Charlie's Place. _____ Please ask my child to call me or an emergency contact person and have my child remain inside Charlie's Place until he/she can be picked up. _____ Please ask my child to call _______________________________________________________________ (Please write Name and Phone Number) and have my child make arrangements with him/her. _____ Other (Please be as specific as possible)____________________________________________________ ____________________________________________________________________________________ Child(ren)'s Name(s)_________________________________________________________________________ Parent/Guardian Signature_______________________________________________ Date_________________ |
| PLEASE PRINT OUT AND USE AS MANY COPIES OF THIS FORM AS YOU NEED! |
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