Pop Up 1/2 Day Summer Camp of 2024 K Peas Place Registration Form

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Parent's Name* This field is required.
First Name
Middle Name
Last Name
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Additional Caregivers bringing your children* This field is required.Nannies, Grandparents etc.
First Name
Middle Name
Last Name
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Child's Name * This field is required.
First Name
Last Name
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Child's Age* This field is required.
5
Child's Date of Birth* This field is required.
Date
Year
Month
Day
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Sibling- Child's Name
First Name
Last Name
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Sibling- Child's Date of Birth
Date
Year
Month
Day
8
Sibling- Child's Name
First Name
Last Name
9
Sibling- Child's Date of Birth
Date
Year
Month
Day
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Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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E-mail* This field is required.
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Cell Phone* This field is required.
Area Code
Phone Number
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Have we met before, if yes? Where?* This field is required.
K Peas Place Birthday Parties
K Peas Place Special Events
Private class/event
Found you by GOOGLE
Found you by FACEBOOK
Found you by Instagram
referred by a friend
Other
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Add to TEXT reminders* This field is required.texts are sent with daily schedule to confirm attendance the next day. Text is the first line of communication in the event we close or add on sessions, plus exclusive deals are offered.
YESNO
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Add to EMAIL reminders* This field is required.Important information is provided to reference for policy reminders and all the love happening here at K Peas Place! We call LOVE & LOGISTICS!
YESNO
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Image Field
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Are you a NEW family, this is your first time to K Peas Place?* This field is required.We are excited to welcome you!
YESNO
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Check your choice A or B* This field is required.Payment will secure your spots. We will limited this event.
Option A ~ 9:00-12:00p Please send $60 via zelle: kpeasplace@gmail.com
Option B ~ 1:00- 4:00p Please send $60 via zelle: kpeasplace@gmail.com
Other
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Signature - Agree to our Terms and Conditions, Waiver, Refund Policies.* This field is required.Release and Waiver of Liability Form- By signing in /checking in states, I will be participating in K Peas Place activities. I, recognize that there are risks involved in any activity and hereby assume all risk of injury, harm, damage or death in connection with my participation in this activity. I understand and agree that neither K Peas Place and hosting site nor its trustees, officers, directors, employees, agents, landlords, or representatives may be held liable in any way for any injury, harm, damage or death that may occur as a result of my participation in this activity. To the fullest extent permitted by law, I agree to save and hold harmless K Pease Place and hosting site from any claim by myself, my estate, heirs, successors, assigns or other persons arising out of my participation in this activity. I authorize K Peas Place and hosting site through its trustees, officers, directors, employees, agents or representatives to render or obtain such emergency medical care or treatment for me or my child as may be necessary should any injury, harm or accident occur while participating in this activity. I understand and acknowledge that K Peas Place and hosting site does not provide health or medical insurance in connection with this activity and I agree that I will be financially responsible for any bills incurred as a result of medical treatment, including emergency medical treatment and/or transportation to a medical facility, in connection with my/my child’s participation in this activity. By signing I accept email updates, text updates and give permission of K Peas Place to use images of my family for advertising and promotion via social media forums of their business. Unless otherwise noted by you in print upon arrival. Waiver/ Idemnification & Cancellation Policy Submission of this form indicates you have read and agreed to the terms of the waiver below - Waiver/Indemnification: As a parent/legal guardian of the child named herein, I hereby represent that the child has been examined by a pediatrician and is physically fit to participate in K Peas Place Theatre Camp. . I understand there are inherent risks in participating in this program. I hereby accept responsibility for and agree to pay any and all costs of medical treatment resulting from any injury suffered by my child as a result of his/her participation in K Peas Place. I further agree to indemnify and hold harmless K Peas Place, its agents, servants, employees and/or representatives from any and all liability, damage, and costs or expense arising out of my child's participation, of every kind and nature, in K Peas Place events. In the event that I cannot be reached in an emergency, I hereby give permission for care to be administered by a qualified K Peas Place staff member, EMT, physician/staff of a hospital, or any other qualified individual to provide any medical treatment deemed necessary for my child. K Peas Place may use photographs and/or videos of my child while participating in K Peas Place sponsored activities. - Absence from a classes does not qualify student for a partial refund. - Student must commit to full program - Any health concerns that stop a student from participating from our program will be handled on case to case basis. K Peas Place is CLOSED to the public during these weeks. Important: Policies/ Logistics/ more policies: No smoking or vaping Prohibited Items: Any weapons Illegal drugs, alcohol, explosives Contraband tobacco or e-cigarettes Any professional photography equipment Arrival: • Remove shoes – bring grippie socks to wear wear socks· • Leave belongings in the front storage cabinet, bring minimal necessary items/ label if necessary. Pack a snack/lunch with a drink! • Caregivers Sign in at the front desk upon arrival and departure.
Clear
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Terms and Conditions* This field is required.
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