Kids Excel Program Registration Form

Registration Form

The KIDS Excel Program is an out of school time program that offers academic, leadership, and enrichment opportunities for students and families.
Summer Camp Information

Costs: $175/week for one child and $100 for each additional child/week
Child's Name*

First NameLast Name
Student Information
Birth Date*

MonthDayYear
Age*
T-shirt size:*
Grade *
School (24-25)
If Other, list school:
Gender*

MaleFemalePrefer not to sayOther
Race/Ethnicity*

American Indian or Alaska NativeAsianBlack or African AmericanHispanic or LatinoNative Hawaiian or Other Pacific IslanderWhite
Language spoken:*
Allergy/Medical Information
Does your child have any allergies, chronic illness, or medical conditions?*

YesNo
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?*

YesNo
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?*

YesNo
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*

American Indian or Alaska NativeAsianBlack or African AmericanHispanic or LatinoNative Hawaiian or Other Pacific IslanderWhite
Choose all that apply:*

Emergency ContactAuthorized PickupLives with
Parent/Guardian/Caregiver Information 2
Name

First NameLast Name
Best Contact Number

Area CodePhone Number
E-mail
example@example.com
Choose all that apply:

Emergency ContactAuthorized PickupLives with
Language spoken:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Race/Ethnicity

American Indian or Alaska NativeAsianBlack or African AmericanHispanic or LatinoNative Hawaiian or Other Pacific IslanderWhite
Additional Emergency Contact Information
Name

First NameLast Name
Best Contact Number

Area CodePhone Number
Choose all that apply:

Authorized PickupNot Authorized to Pickup
Name

First NameLast Name
Best Contact Number

Area CodePhone Number
Choose all that apply:

Authorized PickupNot Authorized to Pickup
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*

I give my permission for my child(ren) to access the internet for educational purposes under the supervision of program staff.I DO NOT give my permission for my child(ren) to access the internet for educational purposes.
Consent for Use of Photos, Video Recordings, work samples and projects*

I give my permission for use of my child(ren)'s photo, videos, work samples and projects and likenessI DO NOT give my permission for my child(ren) to access the internet for educational purposes.
Communication Agreement*

I agree to accept and respond to any communication methods provided by Kids Excel to ensure that I am receiving information related to my child(ren) and the program. This includes Class Dojo, text messages, phone calls, written correspondence, and emails.
Parent Pickup Agreement*

I understand that the Kids Excel Program does not provide transportation services at this time. I will be responsible for transporting my child(ren) to and from the program. I also understand that they must be picked up from the program by 5:30pm daily. No exceptions.
Enrollment Agreement*

I understand that the Kids Excel Program requires attendance to the parent orientation to complete my child’s enrollment in the program. (Orientation dates will be sent prior to the beginning of the program.)
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:

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Registration Form

Summer Camp Information