2025 2026 Camp Day New Student Registration

462 SW Port Saint Lucie BLVD, Port Saint Lucie FL 34953 Email: Info@KidSpaceRocks.com wwW.KidSpaceRocks.com

Phone: 772-340-2140

Camp Day Registration
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
School Attending
CURRENT GRADE*

GRADE K OR 1GRADE 2 OR 3GRADE 4 OR 5GRADE 6TH THRU 8THPRE -K
Street Address*
City
State
Zip Code
Best DaytimeEmergency Contact Number*
Email For billing receipts*
example@example.com
Parents/Guardians Contact Information
Parents / Guardians Names *
Address if different from above
City
State
Zip Code
Parent 1 Name*
Parent 1 Cell*
Parent 1 Work
Parent 2 Name
Parent 2 Cell
Parent 2 Work
Tell us about your child Every child is unique please use this space to fill us in on any concerns you may have and also make us aware of any behavioral or developmental issues affecting your child in order to better assist us in caring for himher
Allergies/Medical Conditions:
Please check if your child has any of the following allergies
Please list any allergies or Dietary Restrictions your child has
Release For Pick Up

Please name 3 people in addition to Guardians listed on the first page, who may sign out your child from our center without prior written permission. These individuals will be allowed to remove your child from our care without contact from you, after showing a valid driver's license. (Id will be required)
1. Name
Relationship to Child
2 Name
Relationship to Child
3 Name
Relationship to Child
No Contact Order/ Custody Information

Please notify the Director in writing of any persons who are to have no contact with your child. Please include a copy of any No Contact Order per any court decision. This includes custody disputes. By signing below, you state that that you have read and agree to the rules and conditions outlined in the Kid Space Summer Camp Policies and Procedures.

MEDIA RELEASE

I understand that both still and video images may be taken of my child and may be used in advertising material or on Kid Space/ Sochin Martial arts/Wish Me Luck Farms websites, as well as posted to our Facebook or Instagram.
ParentGuardian Signature*

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Date

MonthDayYear
Date
Kid Space Camp Field Trip/Medical Release Form

As the parent/guardian of {studentsName} I hear by grant consent for him/her to participate in Kid Space approved field trips while enrolled in Spring Break or Summer Camp from August 10th, 2024 - August 10th, 2025. I have been advised in writing or by verbal notification of all trips available to my child over the course of the summer, including destinations, dates and travel arrangements.

It is my understanding that Kid Space will advise me by written or verbal notification of any changes to the posted schedule in sufficient time to enable me to communicate any withdrawal of consent for the specific trip or activity. Trip changes will be posted in the front lobby.

I understand that Kid Space LLC and it's subsidiaries will be held harmless from any damages or claims that might arise from injuries out of any act or omission on the part of Kid Space as a result of such a trip or activity.

I understand that travel arrangements for my child include walking to locations within reasonable distances, such as other businesses in our plaza. When walking students will remain on sidewalks and off main roads. When driven my child will be in a Kid Space approved vehicle and driven by an approved driver. AlthoughKid Space vans will be the primary transportation, approved chaperoning parents will be allowed to transport my child as well with prior verbal notification.

As the parent/guardian of the above named student, I hear by give authorization to the staff of Kid Space LLC to transport my child to the nearest emergency room if for any reason they require minor medical treatment. I understand that emergency medical personal may be called to transport at the discretion of the director. I further authorize the hospital it's medical staff to administer treatment as deemed necessary for the well-being of said student. I understand that the staff will make every attempt to notify me in all medical emergencies, and I will be contacted if possible for my permission if hospitalization or treatment of a serious nature is required. I have read and understand the above and freely give my consent and permission of all things contained
ParentGuardian Signature*

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Date
Childs Date of Birth*

MonthDayYear
Date
Childs Weight*
ParentGuardian Contact best daytime number*
I have read and understand the Kid~Space contract. I agree that my credit card may be charged in the event I do not make payments as specified in this contract. I understand that my card may be charged weekly for any outstanding fees owed on my account, including tuition, late fees, returned check fees, or unpaid lunch fees.
Signature*

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