KDCDC Creative Arts Summer Camp 2025 Registration

King's Daughters Child Development Center: Creative Arts Day Camp 2025 Registration

Camper Name*

First NameLast Name

Birthdate*

Date

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Week(s) Attending (check ALL weeks attending below)*

June 9-13June 16-19 **Closed June 20th in observance of Juneteenth holiday**June 23-27All 3 Weeks

School Name*

Grade Entering Fall 2025*

Parent/Guardian - Contact Information

Parent/Guardian #1

Name*

First NameLast Name

Ms./Mrs./Mr./Other

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone (direct)*

Phone (work)

Area CodePhone Number

Occupation

Employer Name

Email*

example@example.com

Do you consent to receiving email updates about Summer Camp? *

Parent/Guardian #2

Name*

First NameLast Name

Ms./Mrs./Mr./Other

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone (direct)*

Phone (work)

Please enter a valid phone number.

Occupation

Employer Name

Email*

example@example.com

Do you consent to receiving email updates about Summer Camp?*

Communication for summer camp families will be made through email and text messaging.

Emergency Contact Information

Alternate Pickup/Release

Emergency Contact #1

Name*

First NameLast Name

Ms./Mrs./Mr./Other

Phone (direct)*

Phone (work)

Please enter a valid phone number.

Relation to Child*

Alternate Pickup/Release

Emergency Contact #2

Name*

First NameLast Name

Ms./Mrs./Mr./Other

Phone (direct)*

Phone (work)

Please enter a valid phone number.

Relation to Child*

Please list names/phone number for people other than parents/guardians that are permitted to pick up your child:

Name

First NameLast Name

Phone Number

Please enter a valid phone number.

Name

First NameLast Name

Phone Number

Please enter a valid phone number.

Name

First NameLast Name

Phone Number

Please enter a valid phone number.

Medical Release Information Insurance Information

Health Insurance Provider*

Or N/A if not applicable

Policy Number*

Or N/A if not applicable

Primary Physician*

Office Name and Address*

Office Name

Street Address Line 1

CityState / Province

Postal / Zip Code

Phone*

Hospital Preference?*

Please indicate name of hospital or N/A if not applicable

Please list any medical issue, including any requiring maintenance medication (i.e. Diabetic, Asthma, Seizures)

Should a paramedic be called for any of the listed medical issues?

If yes, please list which medical issues require a paramedic to be called.

Is your child presently being treated for an injury or sickness, or taking any form of medication for any reason?*

If yes, please explain.

Is your child allergic to any type of food or medication?*

If yes, please explain.

Is your child's updated shot records on file at their local school?*

If no, please explain.

I understand that I will be notified in the case of a medical emergency involving my child. In the event I cannot be reached, I authorize the calling of a doctor and the providing of necessary medical services in the event my child is injured or becomes ill.*

I agree

I understand the King's Daughters Child Development Center or its Creative Arts Day Camp will not be responsible for the medical expenses incurred, but that such expenses will be my responsibility as parent/guardian.*

I agree

Camp Fees Information

PLEASE NOTE: There is a one-time $25.00 registration charge per child. This must be paid in addition to weekly fees in order to reserve a spot for your child.

$190 for the first week attending (this includes the $25 registration fee); 165.00 for the rest of the weeks attending; If you are enrolling two children, there will be a 5% discount for the second child.

The registration charge & fees for all weeks MUST be received to the KDCDC office on the first day of camp. Please allow some extra time for drop-off on that day to make your payment.

Payments can be made by check or money order and brought in or mailed to KDCDC at 590 North Dupont Ave., Madison, TN 37115. You may also pay by debit/credit card in our office (there will be a 2.25% processing fee)

No refunds will be processed for registration charges or weekly camp fees.

_________________

Dropoff: 8:00AM Pick up: 2:45PM (late fees will be assessed)

PLEASE DO NOT DROP OFF YOUR CHILD EARLIER THAN 8:00AM, AND BE ON TIME FOR PICK UP AT 2:45PM.

WE ARE NOT LICENSED FOR BEFORE OR AFTERCARE FOR CAMP PARTICIPANTS. THANK YOU!

*Please bring a lunch for your child(ren) each day. Snacks will be provided daily.*

PHOTO RELEASE

I hereby give permission for my child to be photographed during the KDCDC Creative Arts Day Camp. I understand the photos will be used to keep a journal of activities, to share during power point presentations, and/or reports to our donors and for promotional purposes including fliers, brochures, newspaper and on the internet. I understand that although my child's photograph may be used for advertising, I do not expect compensation and that all photos are property of King's Daughters Child Development Center and its affiliates.*

I give permission for my child to be photographed during the KDCDC Creative Arts Day Camp.I do not give permission for my child to be photographed during the KDCDC Creative Arts Day Camp.

Off-Site Release

I hereby give permission for my child to walk to the Madison Community Center for official King's Daughters Child Development Center Creative Arts Day Camp activities supervised by camp staff.*

I agreeI disagree

King's Daughters Child Development Center is not responsible for lost or damaged personal property. All scheduled events are subject to change. Photos of the children and their quotes may be used for publicity purposes. No refunds will be processed for registration charges or weekly camp fees. In case of an emergency, and if a family physician cannot be reached, I hereby authorize my child to be treated by Certified Emergency Personnel (i.e., EMT, First Responder, and/or Physician

Printed Name of Parent/Guardian*

Your registration will be sent directly to our office once you submit.

Date*

Your registration will be sent directly to our office once you submit.

Parent or Guardian Signature*