Account Holder Name *

This person will typically be an adult 18+

First Name

Last Name

Account Holder Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Account Holder Phone *

(###)

###

####

Club Member Name *

Enter full name of Club member being registered.

First Name

Last Name

Club Member Birthday *

MM

DD

YYYY

Emergency Contact *

First Name

Last Name

Emergency Contact Phone *

Country

(###)

###

####

Preferred Day(s) *

Choose all that apply

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Juice Works 3D Experience *

Tell us what, if any, experience you have with Juice Works 3D

Iron Level (I'm either brand new to Juice Works 3D; I've completed a half day summer camp or; I've completed week-long after school program)

Silver Level (I've completed a week-long summer camp)

Gold Level (I've completed all Silver level requirements for one or more tracks)

Homeschooled?

Yes

No

Membership Terms *

I have read, understand, and agree to the Membership Terms listed above.

Yes

No

Privacy *

As the person, and/or parent/guardian of the student, registering, you consent to the internal, non-public disclosure of your address, telephone number and email addresses to Juice Works 3D LLC and any official third parties if applicable (i.e. learning center site sponsors, etc.) we work with for the purposes of administering the program. This includes facilitating program communications. You provide this consent with the knowledge that Juice Works 3D LLC will not further disclose your contact information to anyone outside of Juice Works 3D LLC and official third parties without your consent.

Yes

No

Medical Release *

I give permission to the Coaches and/or site sponsor leaders of Juice Works 3D, LLC to secure emergency medical or surgical treatment for my child if there is insufficient time to contact me, and to secure routine, non-surgical medical care as needed.

Yes

No

Waiver of Liability *

I agree to indemnify, release and hold harmless Juice Works 3D, LLC, and their respective officers, agents, employees and volunteers from any and all costs, liabilities, expenses, claims, compensation, demands, or causes of action on account of any loss or damage to person or property of the aforementioned Member arising out of or in connection with his/her/their participation in the aforementioned Membership activities.

Yes

No

Media Release *

I hereby give Juice Works 3D, LLC, their assigns and legal representatives the irrevocable right to use photograph or video images of me as participating Innovator and/or my child Innovator in all forms and media for education or other lawful purposes in its publications and displays. I waive my right to preview or approve the finished product, including written copy that may be created in connection therewith. I understand no fee will be paid to me now or in the future. I have read this release and understand its contents.

Yes

No

Code of Conduct *

I will treat fellow Club members, Juice Works 3D Coaches and staff, with respect at all times, including: respectful listening, participation during activities, avoid distracting and disrespectful language and/or behavior, and follow directions from Juice Works 3D Coaches and staff as necessary to ensure a safe and enjoyable experience by all. I understand that Juice Works 3D reserves the right to exclude my participation in this program if my participation or behavior is deemed detrimental to the safety or welfare of other participants and/or safe completion of activities. I understand that cell phones and electronic games are permitted during breaks only and will be placed in a secure location (cubby, purse, backpack, etc.) in the designated location. I acknowledge that failure to adhere to this code of conduct can result in termination of Club membership with no refund.

Yes

No

Refund Policy *

I understand that Monthly Club membership auto-renews each month on the same date as your initial registration. No refunds will be issued after the first week of each new month, or after your first hour of session time of that month. Club membership can be cancelled using the "Cancel subscription" link provided in your Order Receipt.

Yes

No