Kids Excel Program Registration Form

Child's Name

First NameLast Name

Student Information

Birth Date

MonthDayYear

Age

T-shirt size:

Grade

School (24-25)

If Other, list school:

Gender

Other

Race/Ethnicity

Language spoken:

Allergy/Medical Information

Does your child have any allergies, chronic illness, or medical conditions?

If yes, please describe in as much detail as possible. Kids Excel staff will follow up.

Will your child need to take any medications during the program?

If yes, please describe in as much detail as possible. Kids Excel staff will follow up.

Are there any activities in which the child should not participate and/or physical restrictions?

If yes, please describe in as much detail as possible. Kids Excel staff will follow up.

Consent for Emergency Medical Treatment

I, being a person authorized by law to give such permission, do hereby give my permission for emergency medical treatment to be given to the student listed on this form. I understand that all reasonable attempts will be made to contact me as soon as possible after the condition necessitating treatment arises, and, if unable to reach me, all reasonable attempts to contact the alternate listed above will be made. I understand that all reasonable precautions will be taken for safety at all times. I further release Koinonia Community Solutions and all persons associated with this organization from any liability associated with any accident, injury or disease to the student listed on this form.I do not hereby give my permission for emergency medical treatment to be given to the student(s) listed on this form. I understand that all reasonable attempts will be made to contact me as soon as possible after the condition necessitating treatment arises, and, if unable to reach me, all reasonable attempts to contact the alternate listed above will be made. I understand that all reasonable precautions will be taken for safety at all times. I further release Koinonia Community Solutions and all persons associated with this organization from any liability associated with any accident, injury or disease to the student listed on this form.

Parent/Guardian/Caregiver Information 1

Name

First NameLast Name

Best Contact Number

Area CodePhone Number

E-mail

Language spoken:

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Race/Ethnicity

Choose all that apply:

Parent/Guardian/Caregiver Information 2

Name

First NameLast Name

Best Contact Number

Area CodePhone Number

E-mail

example@example.com

Choose all that apply:

Language spoken:

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Race/Ethnicity

Additional Emergency Contact Information

Name

First NameLast Name

Best Contact Number

Area CodePhone Number

Choose all that apply:

Name

First NameLast Name

Best Contact Number

Area CodePhone Number

Choose all that apply:

Household Information-this information is gathered for grant purposes only and will be kept secure and confidential.

Household size:

Use chart below to select Income Level Limit for Household Size.

Example: 3-person household making $52,000 equals Not Low/Moderate Income Limits

Informed Consent and Acknowledgement

All information will be strictly confidential. Please select one of the following choices for accessing this information and for program quality enhancement purposes.

Consent for Internet Usage

Consent for Use of Photos, Video Recordings, work samples and projects

Communication Agreement

Parent Pickup Agreement

Enrollment Agreement

Summer Camp Theme Dates. Choose week(s) for student to attend: (Each week will have 36 slots on first come, first serve basis)

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.

Signature:

Registration Form

Summer Camp Information