Kindergarten Enrichment 2025-2026

Kindergarten Enrichment

Registration 2025-2026
Child's Name*

First NameLast Name
Birthdate*

MonthDayYear
Date
Gender*
Age*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
School (Fall of 2025)*
Parent/Guardian*

First NameLast Name
Phone Number*

Area CodePhone Number
Parent Primary E-Mail Address*
example@example.com
Contact Person in case of emergency*
Relationship to child*
Emergency Contact Phone*

Area CodePhone Number

1. I understand that as the parent/guardian submitting this registration form on behalf of the above named child, that I, alone, am responsible for payment of the program fees in accordance with the following schedule: All program fees are due the first Monday for each month. Payments can be made via Venmo (@Summercityadventures) or Zelle (josh@summercityadventures.com).
2. I understand that ALL FORMS must be filled out, signed and returned with the Registration Form.
3. I give permission for my child to participate in any and all program activities, except those specifically prohibited, in advance, and given to the Program President in writing.
4. I give permission for my child to go outside the program facility.
5. I give my permission for my child to be included in program photos, videos, or multimedia presentations.
6. I understand that Josh Sutter and Music Makers are not responsible for the personal property of my child, or damage/loss of my child’s personal property while participating at the programs facility.
7. I hereby release and hold harmless Josh Sutter, Music Makers, its officers, employees, agents, representatives, volunteers, heirs, executors, and assigns from all liability for personal injury, including death arising out of my child’s participation in this program. I understand that this release and indemnification releases liability for the conduct of Josh Sutter, Music Makers and its officers, employees, agents, representatives, volunteers, heirs, executors and assigns.
8. In the event I cannot be reached in an emergency involving my child, I hereby give permission to the appropriate medical personnel, selected by Josh Sutter to provide medical treatment deemed necessary by such medical personnel, including, but not limited to X-rays, tests, injections, blood transfusions, hospitalization, anesthesia and surgery.
9. I give permission for my child's phone number and parent email address to be shared with other parents on a written list.
10. I understand all social distancing guidelines must be followed in accordance with the IDPH and the CDC.
11. All payments are non-refundable.
Parent/Guardian Signature / Date*

Kindergarten Enrichment

Intake Form 2025-2026
Child's Name*

First NameLast Name
1. Family Background
Primary Daytime Caregiver:*

First NameLast Name
2. Health History
Allergies
If applicable, please describe the typical allergic reaction of your child.
Medications
(If medicine is to be administered at camp, please call the Program Office 815-354-0662 for a Physician's Medical Release Form that must be completed by your child's doctor.)
Food restrictions:
3. Health Insurance Information
Carrier or Plan Name*
Group Number*
4. Please provide any additional information you feel would be helpful in getting to know your child:
Parent/Guardian Signature / Date*

Program Sessions
AM Two-Day (Waitlist)AM Three-Day (Waitlist)AM Five-Day (Waitlist)PM Two-Day (Waitlist)PM Three-Day (Waitlist)PM Five-Day (Waitlist)
Payment
$200 Nonrefundable deposit to reserve spot

Payment Options:

Zelle: josh@summercityadventures.com

https://www.zellepay.com/get-started

Venmo: @Summercityadventures

https://venmo.com

•••

*Payment due the first Monday of each month.

*Payment due each week regardless of attendance
(i.e. sickness or vacation)
Should be Empty:

Kindergarten Enrichment

Kindergarten Enrichment

Program Sessions

Payment