2025 Kids Excel Program Summer Camp Registration Form

Allergy/Medical Information

Does your child have any allergies, chronic illness, or medical conditions?*

YesNo

Will your child need to take any medications during the program?*

YesNo

Are there any activities in which the child should not participate and/or physical restrictions?*

YesNo

If yes to any questions above, 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*

E-mail*

example@example.com

Language spoken:*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Race/Ethnicity*

Choose all that apply:*

Emergency ContactAuthorized PickupLives with

Parent/Guardian/Caregiver Information 2

Name

First NameLast Name

Best Contact 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

Additional Emergency Contact Information

Name

First NameLast Name

Best Contact Number

Choose all that apply:

Authorized PickupNot Authorized to Pickup

Name

First NameLast Name

Best Contact 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 summer camp. 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.)

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. I ALSO UNDERSTAND THAT I WILL BE PAYING THE ONE-TIME $50 REGISTRATION FEE PRIOR TO SUBMISSION OF THIS FORM.

Signature:

Choose week(s) for student to attend:(Each week will have 36 slots on first come, first serve basis)$50 registration fee due at the time of submitting registration form.

Registration Form

Summer Camp Information: