2023 Summer Youth Fitness Registration Form

2023 Summer Youth Fitness Registration
The KANA Wellness Center invites you to participate in our summer youth fitness program. There is no deadline for registration, and students may attend as many or as few activities as they like. These programs are completely free and are open to all participants entering grades 2-8 in the 2023-24 school year. Younger and older kids will be divided into two groups. Summer Youth Fitness classes are facilitated by KANA staff and adult volunteers.

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Event Information

Start Date: June 5th, 2023

End Date: August 16th, 2023

Days: Monday & Wednesday

Time: 10:00 AM to 11:00 AM

Location: Baranof Park - Meet Under Score Board

Inclement Weather: We will use the Tom Simpler Gym (auxilary gym) at Kodiak High School

Juneteenth Holiday: On June 19th we will not hold a class.

Students should bring the following items EVERY time they attend.

KANA is not responsible for any lost or stolen property, so please put names on personal items.
- Appropriate footwear: No sandals, flip-flops, or open-toe shoes.
- Weather-appropriate clothes: The program will utilize the field most days, even in light rain or wind. You will NEED a jacket or hoodie.
- Full water bottle. One (1) reusable water bottle will be given to every participant. DO NOT bring soda or energy drinks to the program.
- Please do not bring food to the program unless medically nessessary.
STUDENT INFORMATION
This program is funded by several State and Federal grants, and we hope to include students of all backgrounds. Demographic information is used anonymously for grant reporting.
Participant Name*

First NameLast Name
Participant age:*
What grade will you be during the 2023-2024 school year?*
Alaska NativeAmerican IndianAsianBlack/African AmericanWhiteNative HawaiianPacific IslanderOther
Not Spanish/Hispanic/LatinoSpanish/Hispanic/Latino
Have you participated in Summer Youth Fitness before?*
T-shirt size*
PARENT/GUARDIAN INFORMATION
Parent/Guardian Name*

First NameLast Name
Cell Phone*
Format: (000) 000-0000.
Parent Guardian Email*
example@example.com
EMERGENCY CONTACT

Please list someone that is not already listed as the parent/guardian
Emergency Contact Name *

First NameLast Name
Relationship*
Emergency Contact Phone Number*
Format: (000) 000-0000.
MEDICAL INFORMATION
Family Doctor*
Doctor Office Phone Number*
Format: (000) 000-0000.
Participant's Health Insurance Name*
Health Insurance Policy Number*
Please list below any medications, allergies, or limitations (physical, educational, etc.) you may have that KANA staff and/or other adult volunteers may need to know about:*
STATEMENT OF CONDUCT

Youth Participant and Parent/Guardian must sign
I understand that when I attend Summer Youth Fitness I will comply with this agreement:
- I will stay with the group at all times.
- I will respect the adults attending by following directions.
- I will not criticize or make fun of other group members.
- I will not use inappropriate language.
- I will not use tobacco, vapes, alcohol, or other drugs/substances during or before the program.
- I will not litter or harm the environment.
- I will respect property, whether my own or someone else's.
- I will obey all safety instructions given to me by adult staff.
I understand that if I do not abide by the above agreement, it may result in the following consequences:
- I will only be warned once before my parents are called.
- I may be asked to take one break from the Summer Youth Fitness.
- My parents may have to pick me up, depending on the severity of the incident.
- I may not be welcome back to the program for the remainder of the time.
Participant Signature*

Clear
Date*

MonthDayYear
Date
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date
ACKNOWLEDGEMENT OF RISK & LIABILITIY
As a parent/legal guardian of a participant in the Summer Youth Fitness program, I acknowledge that there are certain risks of injury or death and I expressly and voluntarily assume those risks which I or my child may sustain as a result of participating in any and all activities connected or associated with the Summer Youth Fitness program.I release all claims which may arise against, and agree not to sue the Kodiak Area Native Association (KANA) and its officers, agents, employees and authorized volunteers on my behalf or on the behalf of my child/ward as a result of participating in the Summer Youth Fitness program.I further agree to indemnify, hold harmless and defend KANA and its officers, agents, employees and authorized volunteers from any and all claims by other parties resulting from injuries, damages and losses caused by me or my minor child arising out of, connected with, or in any way associated with the activities of the Summer Youth Fitness program.In the event of a medical emergency, I authorize KANA or their designated agents to obtain medical treatment for the minor in the event of my absence. If I am unable to be reached, I hereby authorize the physician or hospital to which the minor is taken to perform all medical services or to have such medical services performed which in the opinion of the physician or hospital are reasonably necessary to the care of the minor.I also understand that the KANA Wellness Department is not a licensed child care center. I have carefully read this document and fully understand its contents. I am aware that this is a release of liability and indemnification, and I have signed it voluntarily. I hereby verify that I am signing this as the parent or legal guardian of the participant and that it is binding upon me, my successors, heirs, representatives, assigns and executors. I understand this agreement shall not be modified orally. This document will be kept by the KANA Wellness Department and, if requested, shall be provided to me for my records.
Participant name

First NameLast Name
Date*

MonthDayYear
Date
Parent/Guardian's Signature (Must sign if participant is under 18 years of age)*

Clear
PHOTO/VIDEO RELEASE
I hereby authorize KANA or their designated agents to use the photographs, video, recordings, and/or any other record of these events taken of me for use in printed and/or online publications. I am aware that these publications will be used to show the success and outcomes of KANA programs. I acknowledge that since my participation in KANA publications is voluntary, I will receive no financial compensation. I may at any time withdraw permission for photos or video footage of me to be used in any publications.
Date

MonthDayYear
Date
Parent/Guardian Signature (Must Sign if Participant is under 18 years of age)

Clear
Should be Empty:

2023 Summer Youth Fitness Registration

STUDENT INFORMATION

PARENT/GUARDIAN INFORMATION

EMERGENCY CONTACT

MEDICAL INFORMATION

STATEMENT OF CONDUCT

ACKNOWLEDGEMENT OF RISK & LIABILITIY

PHOTO/VIDEO RELEASE