2023 afterschool program Registration Form

2023 KIMS USA AFTERSCHOOL PROGRAM

Registration Form (Reg Fee: $50 | Weekly Fee $199/week)
Student Information
Student Name*

First NameLast Name
Birth Date*

MonthDayYear
Gender*

MaleFemale
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Information
Name*

First NameLast Name
Home Number
Cell Number*
E-mail*
example@example.com
Emergency Information
Emergency Contact's Name*

First NameLast Name
Relationship*
Phone Number*
Alt. Phone Number
SCHOOL INFORMATION
Your child will be transported or pick up at the following school*
If other please fill in
Child's Grade Level*

Kindergarten1st Grade2nd Grade3rd Grade4th Grade5th GradeOther
Elementary School Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
School Phone*
Please enter a valid phone number.
MEDICAL INFORMATION
Does the student have any allergies, chronic illness, or medical conditions? If yes, please describe.
Is the student prescribed an inhaler? If yes, please explain any instructions.
Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by KIMS USA during the selected afterschool program. In exchange for the acceptance of said child’s candidacy by KIMS USA ., I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless KIMS USA . and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected afterschool sessions.

In case of injury to said child, I hereby waive all claims against KIMS USA. including all coaches and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event. There is a risk of being injured that is inherent in all sports activities, including basketball. Some of these injuries include, but are not limited to, the risk of fractures, paralysis, or death.
Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Date*

MonthDayYear
Date
Signature*

Clear
Should be Empty:

2023 KIMS USA AFTERSCHOOL PROGRAM

Student Information

SCHOOL INFORMATION

MEDICAL INFORMATION