Kids Connection Fall Registration

Emergency Contact Information
Please list three emergency contacts (other than parents/guardian) that we may contact in the event of an emergency. These people will also act as authorized adults to pick up you child.
Pickup Name 1 *

First Name Last Name
Phone Number

Area Code Phone Number
Relationship
Pickup Name 2

First Name Last Name
Phone Number

Area Code Phone Number
Relationship
Pickup Name 3

First Name Last Name
Phone Number

Area Code Phone Number
Relationship

Medical Information
Food Allergies: *
Type 'None' if {childsName} has no food allergies.
Medical conditions that Kids Connection leaders need to be aware: *
Type 'None' if {childsName} has no medical conditions to report.
Family Doctor Name *
Family Doctor Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Family Doctor Phone Number *

Area Code Phone Number

Transportation Agreement
I am the parent or guardian of the undersigned child. I hereby authorize Plainfield United Methodist Church and/or Kids Connection (the “Organization”) to transport my child to and from any of the Organization’s activities (the “Transportation”) and I hereby release and waive any claims against the Organization, its organizers, directors, officers and volunteers arising from the Transportation. To the extent any claims are asserted against the Organization relating to the Transportation, I agree to indemnify and hold the Organization harmless from and against any and all liabilities, losses, damages, expenses and claims of any kind including reasonable attorneys’ fees. This waiver applies even though said liability may arise out of negligence or carelessness on the part of the Organization, except that I will have no obligation to indemnify the Organization to the extent that any claim of a third party arises solely from the intentional and willful misconduct of the Organization. This document shall be binding upon my heirs, representatives, successors and assigns and shall be construed in accordance with the laws of the State of Indiana. If any provision in this document is held to be unenforceable, it is agreed that the remaining provisions hereof shall continue in full force and effect.
Transportation Agreement. *

I agree to the above Transportation Agreement
My child needs to ride in a booster seat: *

Yes No

Program Information
Registration Fee: $25 for mornings only, $50 for afternoons only and $75 for both mornings and afternoons.

Tuition: Payment can be in the form of cash or check (made out to Kids Connection) mailed to: Kids Connection, 600 Simmons Street, Plainfield 46168. Payment can also be made online at the Kids Connection Payment portal.

Tuition is paid for the month(s) your child is enrolled - whether or not your child attends the full month(s).

Please check the appropriate program(s) *

Morning Only - 6:30am-8:30am - $130/month Afternoon Only - 3:50pm-6pm - $210/month Both Morning and Afternoon - $340/month
We would like to use pictures of the Kids Connection students in brochures, and on the church website and Facebook page. We will not include students’ names or any other information.
Consent for use of picture(s) *

Yes, you may use {childsName}’s picture in this way. No, you may NOT use {childsName}’s picture in this way.
I understand that I will be notified of {childsName} acceptance into the KIDS@PUMC Kids Connection Program via email.

I agree that upon {childsName} acceptance into the KIDS@PUMC Kids Connection program, I agree to pay a NON-REFUNDABLE registration fee by cash or check or online at the Kids Connection Payment portal before 6:00 pm the next business day.

Please make checks payable to Kids Connection.

Registration Fees:

Parent/Guardian Information