Family information
Parent 1 Name
*
First Name
Last Name
Parent 1 Cell Number
*
-
Area Code
Phone Number
Parent 1 Employer
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent 1 Work Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent 1 Work Number
-
Area Code
Phone Number
E-mail
*
example@example.com
Parent is authorized to pick-up child
*
Yes
No (Court documents required)
Parent 2 Name
*
First Name
Last Name
Parent 2 Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent 2 Cell Phone
*
-
Area Code
Phone Number
Parent 2 Employer
*
Parent 2 Work Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent 2 Work Number
-
Area Code
Phone Number
Parent 2 Email
example@example.com
Parent is authorized to pick-up child
*
Yes
No (Court documents required)
Child information
*
Rows
Child's Name
Birthdate
Gender
Child's Grade
Child's shirt size
Child 1 Name
Child 2 Name
Child 3 Name
Child 4 Name
Child 5 Name
My child attends the following school/pre-school and his/her immunization record is on file at the school and all required immunization test are current. Vision and hearing screening records are also on file.
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Birnham Woods Elementary (31150 Birnham Woods Dr, Spring, TX 77386, 832-663-4200)
Snyder Elementary (28601 Falls Lake Dr, Spring, TX 77386, 832-663-4400)
Bradley Elemtary (4200 Falls Lake Dr, Spring, TX 77386, 832-482-6800)
Kauffman Elementary (2760 Northridge Forest Dr, Spring, TX 77386, 832-592-5600)
Broadway Elementary (2855 Spring Trails Bend, Spring, TX 77386, 281-465-2900)
Hinse Elementary (27980 Woodbridge Cove Drive, Spring, TX 77386,281-939-4800)
Crippen Elementary (18690 Cumberland Blvd, Porter, TX 77365, 281-577-8740)
Other school (will list below)
Not in school. Immunization records to be provided by parent
Other school/pre-school if not listed above (school address and phone number)
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Emergency Contacts and Authorized pick ups
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Rows
Full Name
Address
Contact Number
Relationship
1
2
3.
4.
I give permission to receive periodic text messages in case of emergencies and/or school closures
*
Yes
I understand that I am financially responsible for tuition if I do not give a full 2 week notice in writing upon withdrawal
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Yes
My child has permission to be released to the care of a sibling under the age of 18 years old.
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Yes
No
If yes to the previous question, please list the siblings name(s).
Emergency Medical care: I authorize Kids in Action, in an emergency, to act in my behalf for my child's sake and to have my child transported to the nearest medical facility
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Yes
Child's pediatrician Name
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Child's Pediatrician Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Child's Pediatrician Phone Number
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Area Code
Phone Number
I understand that I may not bring my child to Kids in Action when he/she is exhibiting any of the following: a temperature of over 100, 3 or more bouts of diarrhea or vomiting, any undiagnosed rash, or sore, or discharging eyes or ears, or profuse nasal discharge. If my child is sent home, they must remain out a minimum of 24 hours and cannot return until they a symptom free and unmedicated for at least 24 hours.
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Yes
I understand that Kids in Action staff will only administer medication under the certain conditions: accompanied by a medication form that must be signed by the parent/legal guardian, all prescription medication must be in the original packaging and only if a physician has dispensed it with the student's name on it and all medicine must be stored in locked, childproof containers(not in child's backpack)
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Yes
List any and all previous illnesses, broken bones, surgeries, etc.
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Are there any restrictions on normal activities? If so, please explain.
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Is your child physically and mentally able to participate in group activities?
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Yes
Is your child free from infection and contagious disease?
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Yes
No
I understand that there is always some risk of injury due to accident while children are playing together and that unless any injury is a direct result of abuse of obvious negligence by Kids in Action employees, I will not hold Kids in Action or its employees responsible.
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Yes
Does your child have any special needs the staff needs to be aware of (ADD, Autism, Epi-pen, speech, etc)? If so, please send a copy of the child's IEP.
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List any known allergies or medications (allergy form must be completed and returned to be kept on file).
*
I consent to my child’s photo being taken, shared with me so we can see what's going on throughout the day, and used in school advertising or promotional materials (please type your name in acknowledgement).
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Please check all of the permissions that you agree to for your child(ren):
*
Rows
Yes
No
N/A
play and participate in all on-site activities
play on the outdoor playground/slack line (age appriate)
watch movies at the center that staff select (rated G or PG
play video games that are age appropriate
participate in water activities (sprinklers, water hoses, water slides and slip and slide)
swimming in the onsite pool w/certified lifeguard on duty (schoolers group only)
participate in Archery and Slack line Course (school groups only)
participate in Razor drifting trike activities(school group ONLY)
participate in Ninja Warrior and Nerf Wars (school groups only)
Have KIA bug spray/sunscreen applied as needed (NO-AD SPF 50 & Cutter Sensations w DEET) required unless we have doctors note
My child has permission to be transported to and from Showbiz Cinema in the event of a field trip cancellation. There will be 24 hours notice (Freshman-Senior only)
I have read and understand Kids in Action's policy on discipline and guidance
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Rows
Yes
Discipline must be: individualized and consistent for each child, appropriate to the child's level of understanding, and directed toward teaching the child acceptable behavior and self control
A care giver may only use positive methods of discipline and guidance that encourages self-esteem, self-control, and self-direction which include at least the following: using praise and encouragement of acceptable behavior instead of focusing on unacceptable behavior, redirecting behavior using positive statements, reminding children of behavior expectations daily using clear and positive statements, and using brief supervised separation or time out from the group, when appropriate for the child's age and development, which is limited to no more that one minute per each year of the child's age
There must be NO harsh, cruel or unusual treatment of any child. The following types of discipline and guidance are PROHIBITED: corporal punishment or threats of corporal punishment, punishment associated with food, pinching, shaking or biting a child, hitting a child with a hand or instrument, putting anything in or on a child's mouth, humiliating, ridiculing, rejecting or yelling at a child, subjecting a child to harsh, abusive or profane language, placing a child in a locked or dark room, bathroom or closet with the door closed, and requiring a child to remain silent or inactive for inappropriately long periods of time for the child's age
All of the above are in accordance with Texas Administration code, title 42, chapter 746-747, subchapters L, discipline & guidance.
I have read and understand Kids in Action's policy on termination for cause.
*
Rows
Yes
Children: bullying, defacing and/or destroying center property or the property of others, engaging in aggressive behavior toward other children and/or staff members including, but not limited to: spitting, yelling, hitting, kicking. being rude and/or discourteous to any staff member, using foul language on the premises, stealing from the center, staff or other children, refusing to remain with assigned group, horse playing in the swimming pool or on a field trip
Parents: engaging in aggressive behavior toward a child and/or staff member of the center, failure to call if child's schedule changes that affect drop off/pick up from school, failure to follow check in/out procedures, using foul language on the premises, being rude and/or discourteous to any staff member, failure to provide the necessary enrollment forms and/or information to the center, and failure to pay accurate and current fees. All fees are due the Monday before the following camp week. Any fee not paid by the 2nd day following the scheduled payment day, will be charged a late fee payment of $15. NO EXCEPTIONS
By typing my name below I acknowledge and agree that all information is true. I agree to abide by the policies listed in this form.
*
Please upload a clear picture(s) of your child(ren) so we can add it to their account (you can upload more than one picture for multiple children):
*
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Camp Tuition agreement
Payment for my child's program is due on MONDAY of the current week. Tuition is due whether my child attends or not. All accounts must by set up on automatic payment plan for tuition. Tuition will be deducted directly out of checking accounts. A $15/day late fee will be added if not paid by the end of business on Monday. If tuition and/or late fees are not paid by Friday, then I understand that my child cannot return to care the following Monday until paid. A $5/per week discount will be given to all accounts who use a checking/savings account for auto charge payment (please type your name)
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INCLEMENT WEATHER, PANDEMIC OR OTHER RELATED CLOSINGS: Kids in Action follows Humble ISD closings. Please check local TV stations and web sites for announcement of closing. Full tuition is due during inclement weather times. If extended circumstances exist, such as a flood or pandemic, where the center is closed for an extended amount of time, then the following tuition policy will apply
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Rows
Please check each box below
INCLEMENT WEATHER, PANDEMIC OR OTHER RELATED CLOSINGS: Kids in Action follows Humble ISD closings. Please check local TV stations and web sites for announcement of closing. Full tuition is due during inclement weather times. If extended circumstances exist, such as a flood or pandemic, where the center is closed for an extended amount of time, then the following tuition policy will apply
After 3 weeks, 50% tuition will be due until the child returns
If you choose to withdraw your child, a 2-week notice and full tuition is required. After 2-weeks, your child’s spot will not be held, and a new registration fee will be required to re-enroll, if openings remain.
If Kids in Action is closed, and children are unable to attend, then the following tuition schedule applied
*
Rows
Please check each box below
Full tuition is due for 3 weeks following the closure
50% tuition will be deducted for 3 weeks following
After 6 weeks of closure, no tuition will be collected, and the children’s spots will be held
In case of serious emergencies such as earthquakes, fire, storms, or loss of power/water, parents will be notified, if possible, and children will be cared for until parents or emergency contacts arrive.
In the event of a NSF check/ACH return, a $35 penalty fee will be added to my account. If Kids in Action receives 3 or more NSF checks/ACH returns in one year, your enrollment may be terminated (please type your name).
*
Kids in Action is licensed by The Texas Department of Family and Protective Services. Operating hours are Monday-Friday from 6:30 am to 6:30 pm, and we can only care for children during these specified times. A late fee of $10 for the first 10 minutes, and an additional $1 per minute will be charged to your account (please type your name).
*
In the event your child forgets his/her KIA t-shirt on a field trip day, a $15 charge will be applied to your account (please type your name).
*
Proper attendance tracking is imperative to the safety of the children enrolled. All parents are required to sign their children in and out each day. When a family fails to sign their child in or out, a $5 penalty fee will be applied to your account for each occurrence (please type your name).
*
Kids In Action chooses not to get involved in custody disputes. In the event a court order is on file, Kids In Action will not acknowledge which party is responsible for payment of tuition fees. These arrangements must be coordinated between the two parents. Late fees and withdraw guidelines will still apply regardless of which parent is responsible for tuition fees (please type your name).
*
Payment
The camp tuition must be paid in full in order to secure placement.
I understand that the registration fee is non refundable (please type your name).
*
All tuition payments are payments to hold the child's space in the program. Tuition is due regardless of attendance (please type your name).
*
If I choose to end my relationship with Kids in Action and withdraw my child, a 2 week notice will be given in writing. I understand that I am financially responsible for tuition if I do not give a full 2 week notice in writing upon withdrawal (please type your name).
*
If at any point my account becomes delinquent, I understand that any credits or discounts will be removed from my account (multiple child discount, First Responders, etc.) (please type your name).
*
My Products
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Spring Break Camp-CISD-SCHOOL AGE- FULL WEEK - Monday-Friday (3/9-3/13)
$
294.00
Spring Break Camp-CISD-FULL WEEK - SCHOOL AGE - Monday-Friday (3/9-3/13)
Quantity
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Spring Break Camp-CISD-SCHOOL AGE- DAILY RATE - MONDAY, 3/9
$
65.00
Spring Break Camp-CISD-Daily Rate - SCHOOL AGE - MONDAY 3/9
Quantity
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Spring Break Camp-CISD-SCHOOL AGE- DAILY RATE - TUESDAY, 3/10
$
65.00
Spring Break Camp-CISD-Daily Rate - SCHOOL AGE - TUESDAY 3/10
Quantity
1
2
3
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Spring Break Camp-CISD-SCHOOL AGE - DAILY RATE - WEDNESDAY, 3/11
$
65.00
Spring Break Camp-CISD-Daily Rate - SCHOOL AGE -WEDNESDAY 3/11
Quantity
1
2
3
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Spring Break Camp-CISD-SCHOOL AGE - DAILY RATE - THURSDAY, 3/12
$
65.00
Spring Break Camp-CISD-Daily Rate - SCHOOL AGE THURSDAY 3/12
Quantity
1
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Spring Break Camp-CISD-SCHOOL AGE - DAILY RATE - FRIDAY, 3/13
$
65.00
Spring Break Camp-CISD-Daily Rate - SCHOOL AGE -FRIDAY 3/13
Quantity
1
2
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9
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Spring Break Camp-CISD-PRE-SCHOOL AGE- FULL WEEK - Monday-Friday (3/9-3/13)
$
325.00
Spring Break Camp-CISD-FULL WEEK - PRE-SCHOOL AGE - Monday-Friday (3/9-3/13)
Quantity
1
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Spring Break Camp-CISD-PRE-SCHOOL AGE- DAILY RATE - MONDAY, 3/9
$
65.00
Spring Break Camp-CISD-Daily Rate -PRE- SCHOOL AGE - MONDAY 3/9
Quantity
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9
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Spring Break Camp-CISD-PRE-SCHOOL AGE- DAILY RATE - TUESDAY, 3/10
$
65.00
Spring Break Camp-CISD-Daily Rate - PRE-SCHOOL AGE - TUESDAY 3/10
Quantity
1
2
3
4
5
6
7
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9
10
Spring Break Camp-CISD-PRE-SCHOOL AGE - DAILY RATE - WEDNESDAY, 3/11
$
65.00
Spring Break Camp-CISD-Daily Rate - PRE-SCHOOL AGE -WEDNESDAY 3/11
Quantity
1
2
3
4
5
6
7
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9
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Spring Break Camp-CISD-PRE-SCHOOL AGE - DAILY RATE - THURSDAY, 3/12
$
65.00
Spring Break Camp-CISD-Daily Rate - PRE-SCHOOL AGE THURSDAY 3/12
Quantity
1
2
3
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Spring Break Camp-CISD-PRE-SCHOOL AGE - DAILY RATE - FRIDAY, 3/13
$
65.00
Spring Break Camp-CISD-Daily Rate - PRE-SCHOOL AGE -FRIDAY 3/13
Quantity
1
2
3
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5
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Staff Child
$
Free
Used for staff children. Please notify front desk of your days registering for
Quantity
1
2
3
4
5
6
7
8
9
10
Total
$
0.00
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