Radford Grace-A-Child Academy Summer Camp

School-Age Family Registration Form

Before & After School Care is available exclusively for students attending Christiansburg Primary School and Christiansburg Elementary School. Non-School Day Care is available to all children ages 5–10, regardless of which school they attend.
Payment Assistance Information
Childcare Payment Assistance ~ Please choose one of the following:*
Which county are you receiving assistance from:*
Program Information
How many children are you registering?
*School-Age Care is available for children ages 5–10. If your child is under age 5, please call 540-382-9591 to learn more about our daycare options.
Where did your child previously attend childcare (please type n/a if not applicable)?*
Desired start date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearSchool begins Tuesday, August 11th, 2026
Child Information
Are any of your children NEW to KidZone at Graceachild?*
1st Child's Name:

First NameLast Name
1st Child's Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
1st Child's Gender:
1st Child's School?
CPS (Christiansburg Primary School) & CES (Christiansburg Elementary School)
1st Child - Select a Program:
2nd Child
2nd Child's Name:

First NameLast Name
2nd Child's Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
2nd Child's Gender:
2nd Child's School?
CPS (Christiansburg Primary School) & CES (Christiansburg Elementary School)
2nd Child - Select a Program:
3rd Child
3rd Child's Name:

First NameLast Name
3rd Child's Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
3rd Child's Gender:
3rd Child's School?
CPS (Christiansburg Primary School) & CES (Christiansburg Elementary School)
3rd Child - Select a Program:
4th Child
4th Child's Name:

First NameLast Name
4th Child's Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
4th Child's Gender:
4th Child's School?
CPS (Christiansburg Primary School) & CES (Christiansburg Elementary School)
4th Child - Select a Program:
Medical Information:
Pediatrician's Name:
Pediatrician's Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Child Illness & Communicable Disease:*
Emergency Medical Release & Transport:*
Hospital Emergency Agreement*
Medical Care After Child Leaves the Center:*
Allergies, Special Needs, or Medication:*
Please list your child's name and any allergies, Special Needs, Medications and/or Adverse Reactions to topicals:
Sunscreen Use Authorization:*
Parent Information:

If the primary parent has physical and/or legal custody of the child being registered, please be prepared to provide copies of legal court documents stating this. Please understand that if you do NOT provide this information and you choose NOT to include the secondary parent on this enrollment form, KidZone & Grace-A-Child USA Academy is legally bound to allow the secondary parent access to his/her child after we have properly identified them to do so. We can however alert you if the secondary parent is requesting to see the child.
*Please do not enter the email or phone number of a parent/guardian if you have custody paperwork preventing them from contact as Brighthwheel will issue an invite to them once they are entered* (All custody paperwork is required in order to exclude a parent/guardian)
Who does your child(ren) live with?*
If divorced please provide custody details and a copy of the official papers below:

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1st Parent's Information:
1st Parent's (primary parent) Relation to Child:*
1st Parent's Name:

First NameLast Name
1st Parent's Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
1st Parent's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
1st Parent's Email Address:*
Valid Email Address Required
1st Parent's Employment Status (Va state licensing requires that we obtain your current employers address and phone # if you are currently employed.)*
1st Parent's Employer's Name:*
Employer’s Name:
1st Parent's Employer's Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
1st Parent's Employer's Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
2nd Parent's Information:
2nd Parent's Relation to Child:*
2nd Parent's Name:

First NameLast Name
Is the 2nd parents physical address the same as the 1st parent?*
2nd Parent's Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
2nd Parent's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
2nd Parent's Email Address:
Valid Email Address Required
2nd Parent's Employment Status (Va state licensing requires that we obtain your current employers address and phone # if you are currently employed.)*
2nd Parent's Employer's Name:*
2nd Parent's Employer's Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
2nd Parent's Employer's Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contacts & Authorized Pick-ups:

Virginia State Law requires you to provide a minimum of 2 emergency contacts OTHER THAN the parent(s), that live within 1 hour of your child’s center.If you are new to the area, we allow you 2 weeks to establish emergency contacts. It’s extremely important that you’re available by phone at all times while your child is in our care, especially during the 2 week period of establishing emergency contacts. If this information is not provided within 2 weeks of your child’s first day of attendance, your childcare services may be interrupted until this information is provided to the center.
1st Emergency Contact:
1st EMC Name:

First NameLast Name
1st EMC Relation to Child:*
Relation to Child:
1st EMC Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
1st EMC Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
2nd Emergency Contact:
2nd EMC Name:

First NameLast Name
2nd EMC Relation to Child:*
Relation to Child:
2nd EMC Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
2nd EMC Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Agreements & Consents
KidZone GraceachildUSA Academy Parent Contract:

I agree to review the Parent Handbook found on www.graceachild.org to be fully informed. KidZone and GraceachildUSA Academy, reserves the right to make changes to any policy, procedure, tuition rates, fees, or other processes and information in this parent handbook, rate sheets, or our enrollment forms without prior notice. We reserve this right to maintain licensing compliance, stability, and integrity of the programs, and for the safety and security of the children & families enrolled in our programs, and for the staff that our company employs.UNPAID TUITION & LATE PAYMENT POLICY -- I understand KidZone requires payment by auto debit ONLY. KidZone does not accept cash or checks. I understand that payments are processed on Thursday each week prior to the week of attendance. Should payment be returned the first time unpaid by my financial institution due to non-sufficient funds, Brightwheel will; try to pull the payment and a $35 late fee will be added to my account. If the account remains unpaid by closing time on Friday, my account will be paused and services frozen until payment is made in full. I also understand that non-payment of tuition and fees or an accumulated balance may result in my child's removal from KidZone.I understand KidZone's NO PAUSE tuition policy -- I will be informed via; Brightwheel and/or Facebook, of scheduled closings for holidays, unexpected repairs, or in the case of dangerous weather conditions; and that there will be no pause in tuition, discounts or credits issued for these closings. For inclement weather days, KidZone will do everything possible to be open for childcare without endangering our families or employees travel to and from the center. Should we close due to dangerous weather conditions, we will notify families asap.WRITTEN NOTICE REQUIREMENT FOR WITHDRAWAL -- I understand that a minium of 1 week's written notice is required to withdraw my child from KidZone. Notice must be submitted to the program Director either in person or by Brightwheel messaging. This advance notice allows us to notify families waiting for care and prepare for your child's departure. I understand that if I fail to provide a 1 week written notice, I will be responsible for paying tuition equal to my child's weekly tuition rate for the week notice was not provided.HOLD HARMLESS & LIABILITY WAIVER -- I understand that my child will not be allowed to play on any equipent unless my child meets the height & weight requirements. I acknowledge, release, and hold harmless the facilities, personnel, and property of KidZone & GraceachildUSA Academy from possible injury that could occure while my child is playing on the playground equipment. I give my permission to allow my child(ren) to play on the equipment and acknowledge the risk associated with play.
MEDIA PERMISSION: - KidZone & GraceachildUSA Academy will occasionally use children's pictures or videos on the graceachild.org website, Facebook page, Instagram or on promotional materials. Please let us know whether or not you would mind having your child's photos used in this manner. No names of children will ever be used in any way.*
REQUIRED DOCUMENTS TO ENROLL — Virginia State Licensing requires a copy of your child’s most recent physical and immunizations (or a completed school entrance health form found below), and proof of birth BEFORE a child can start as well as any required medical forms — This must be submitted before your child is officially enrolled. Parents are required to obtain these documents. KidZone does NOT request documents from other schools or doctors. YOU CAN UPLOAD THESE BELOW!

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SCHOOL ENTRANCE HEALTH FORM -- For your convenience, you may click the PDF below to print the “VA School Entrance Health Form”. The form must be completed and signed by the pediatrician and you'll also need your child's immunization record if it is not included.
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School-Age Family Registration Form

Payment Assistance Information

Program Information

Child Information

2nd Child

3rd Child

4th Child

Medical Information:

Parent Information:

*Please do not enter the email or phone number of a parent/guardian if you have custody paperwork preventing them from contact as Brighthwheel will issue an invite to them once they are entered* (All custody paperwork is required in order to exclude a parent/guardian)

1st Parent's Information:

2nd Parent's Information:

Emergency Contacts & Authorized Pick-ups:

1st Emergency Contact:

2nd Emergency Contact:

Agreements & Consents

Please do not enter the email or phone number of a parent/guardian if you have custody paperwork preventing them from contact as Brighthwheel will issue an invite to them once they are entered (All custody paperwork is required in order to exclude a parent/guardian)