KAP Summer Program Registration Form

KAP-Ketchikan Afterschool Program

Summer Program Registration form
No Cost to Participants

About the Ketchikan Afterschool Program (KAP)

Island-wide indoor-outdoor program featuring various workshops with a strong focus on the arts, sports, and outdoor education. The Ketchikan Summer Program (KAP) is open to all Middle School Youth in the 2022-2023 school year. Stay tuned for more details for our 2023 Summer Program!

Participant Information
*
Legal First Name
Last Name*
Legal Last Name
Gender*

MaleFemale
Birth Date*

MonthDayYear
Home Phone*

Area CodePhone Number
Please choose the Trip or Workshop you are signing up for.*
Is there a particular workshop that you are signing your youth up for? If so, please enter the name of that workshop here.

Youth School Information
Grade*
What grade will your student be enrolled in for the 23-24 School Year?
School*
What is the name of the school that your student will attend in the 23-24 school year?
Parent/Guardian Information 1
Full Name*

First NameLast Name
Home*

Area CodePhone Number
Cell*

Area CodePhone Number
Work

Area CodePhone Number
E-mail*

Medical

All health/medical information is protected under HIPAA regulations and is kept in the strictest of confidence among only those staff who will travel with your child. As these activities involve remote locations it is critical our staff are aware of ANY medical conditions, medications or injuries in order to KEEP ALL PARTICIPANTS SAFE.
Does the participant have any injuries or medical conditions which puts themself or other participants at greater risk?*

Yesno
Please explain
Please list any allergies the Participant has. This includes food allergies.*
What are the possible reactions associated with these allergies?*
Remedies/ treatment *
Does the Participant carry an EPIPEN?

yesno
Current, past or chronic injuries requiring medical attention or which have resulted in limited movement or ability*
List any medications the participant will bring on the trip and dosage*

Transportation

These trips involve vehicle transportation, and for the backpacking trips there will be additional boat transportation. Please read the Transportation and Liability Waiver below and if you agree please indicate in the appropriate field.
I permit

Lack of Access to a Vehicle at HomeParent/Guardian Works in the Evening
Signature

Clear

Please press Submit

If all you information is correct your registration is ready to submit. Press the button below to complete your registration.
Please contact me directly if you have further questions about our Summer Programs or any KAP workshops.

THANK YOU!!!

Contact Information:

Director: Andrew Eisenberg

andrewe@rycalaska.com

907-202-5404

www.ricorps.org

Ketchikan Afterschool Program
2417 Tongass Ave
STE# 209(C)
Ketchikan, Alaska 99901
Type a question
Thank You for Your Interest in the Ketchikan Afterschool Program!
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KAP-Ketchikan Afterschool Program