King's Kids Summer Day Camp 2026

King's Kids Summer Day Camp
Enrollment Form
Financial Status
Date:

MonthDayYear
Date
Child's Name:

First NameLast Name
Date of Birth:

MonthDayYear
Date
Age:
School ('26-'27 School Year):
Grade Entering ('26-'27 School Year):
Race/ Ethnicity:
Identifying Marks:
Parent/Guardian Information:
Parent/Guardian Name:
Relationship to Child:
Address:

Street Address

Street Address Line 2

CityState / Province

City / Zip Code
Primary Telephone Number:
Format: (000) 000-0000.
Alternate Number:
Format: (000) 000-0000.
E-Mail
example@example.com
2nd Parent/Guardian Name:
Relationship to Child:
Primary Telephone Number:
Format: (000) 000-0000.
Alternate Number:
Format: (000) 000-0000.
E-Mail
example@example.com
Emergency Contacts: Emergency contacts are also authorized to pick up child unless otherwise noted.
Emergency Contact 1 Name:
Emergency Contact 1 Telephone Number:
Format: (000) 000-0000.
Emergency Contact 1 Relationship to child:
Emergency Contact 2 Name:
Emergency Contact 2 Telephone Number:
Format: (000) 000-0000.
Emergency Contact 2 Relationship to child:
Emergency Contact 3 Name:
Emergency Contact 3 Telephone Number:
Format: (000) 000-0000.
Emergency Contact 3 Relationship to child:
Emergency Contact 4 Name:
Emergency Contact 4 Telephone Number:
Format: (000) 000-0000.
Emergency Contact 4 Relationship to child:
Individuals NOT Authorized for Pick-Up
For the safety of all children, please list any individuals who are NOT permitted to pick up your child from King's Kids Summer Day Camp. If applicable, legal documentation (e.g., court order, restraining order, custody agreement) must be provided and kept on file.
Individuals NOT authorized for pick-up:

King's Kids Summer Day Camp
Enrollment Form
Medical Records Form
Health and Medical Information
Name of Child's Physician:
Name of Medical Facility:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Telephone Number:
Format: (000) 000-0000.
Media Release
Please Check which applies
Media Release Permission
Parent/Guardian Signature:
Date:

MonthDayYear
Date
Field Trips and Off-Site Activities
I give permission for my child to participate in all the regularly scheduled activities, off site, local, and out of town field trips. I understand that I will receive a specific field trip permission form which must be signed and returned for any field trip which requires prior parental authorization and or fees. The program will provide in writing a list of scheduled activities and field trips.
Parent/Guardian Signature:
Date:

MonthDayYear
Date
Parent Service Agreement and Notification
I understand that Martin Luther King Jr. Family Services, Inc. is a multifaceted nonprofit organization that partners with numerous organizations for various reasons. I understand that I and/or my children are exposed to services, assessments, evaluations and programs that are in alignment with the agency's mission and vision statements for the enhancement of program and my child's academic social and emotional success. I understand I will be directly notified of services and activities that my child will be participating in and I will be given dates and times of activities.
Parent/Guardian Signature:
Date:

MonthDayYear
Date

King's Kids Summer Day Camp
Enrollment Form
Travel Information
Do you anticipate your child being absent for three days or more, or on recurring days, during the summer session?
Do you anticipate your child being absent for three days or more, or on recurring days, during the summer session?
Dates of planned or anticipated absences:
Please note: Extended or recurring absences may impact voucher funding and enrollment status. Families are responsible for notifying the program in advance of any planned extended absences.

King's Kids Summer Day Camp
Enrollment Form
Release of Liability
In consideration of being allowed to participate in any way in the Martin Luther King Jr. King’s Family Services, Inc. or MLK Charter Children After-School Program or Summer Camp program, its related events and activities, I, the undersigned, acknowledge, appreciate and agree that:
The risk of injury from the activities involved in this program does exist, and while particular skills, equipment, and personal discipline may reduce this risk, the risk of injury does exist; and,

I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES or others, and assume full responsibility for my participation and,

I willingly agree to comply with the stated and customary terms and conditions for participation. If, however, I observe any unusual significant hazard during my presence or participation, I will remove myself from participation and bring such to the attention of the Agency immediately, and,

I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin. HEREBY RELEASE INDEMNITY, AND HOLD HARMLESS THE MARTIN LUTHER KING JR. FAMILY SERVICES, INC. their officers, officials, agents, and / or employees, other participants, sponsoring agencies, sponsors, advertisers, WITH RESPECT TO ANY AND ALL INJURY, DISABILITY, DEATH, or loss or damage to person or property, WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE, to the fullest extent permitted by law.

I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.
Child's Name:
Child's Age
This is to certify that I as parent/guardian with legal responsibility for this participant, do consent and agree to his/her release as provided above of all the Releases, and for myself, my heirs, assigns, and next of kin, I release and agree to indemnity and hold harmless the Releases from any and all liabilities incident to my minor child’s involvement or participation in these programs as provided above, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES, to the fullest extent permitted by law.
Signature
Date

MonthDayYear
Date

PARENT TRANSPORTATION REQUEST FORM
In limited circumstances, subsidized families may be approved for transportation between home or school and child care. Subject to funding availability, programs will be reimbursed at the Department of Early Education and Care (EEC) approved rate for one way or round trip transportation, based on a family’s need. Subsidy Administrators must assess and document the parent’s need for transportation, taking into consideration such factors as:

(1) the availability of public transportation;

(2) whether a parent has a car;
(3) any physical incapacity of the parent that may prevent the parent from transporting the child; and

(4) whether the parent’s work schedule prevents transportation of the child to or from care.

A family who lives within one half (1/2) mile of the provider will not receive transportation funding, unless exceptional circumstances exist. Please refer to the EEC Financial Policy Guide for guidance.
I am requesting transportation services for my child(ren).
Parent/ Guardian Name
I confirm that:
I am requesting:
Names & Dates of Birth of your child(ren) for whom you are requesting transportation.
Signature of Parent
Date

MonthDayYear
Date

Review and Submit
Should be Empty:

King's Kids Summer Day Camp

Enrollment Form

Parent/Guardian Information:

Emergency Contacts: Emergency contacts are also authorized to pick up child unless otherwise noted.

Individuals NOT Authorized for Pick-Up

King's Kids Summer Day Camp

Enrollment Form

Health and Medical Information and Consent Form

Consent for Medical Care:

King's Kids Summer Day Camp

Enrollment Form

Medical Records Form

Media Release

Field Trips and Off-Site Activities

Parent Service Agreement and Notification

King's Kids Summer Day Camp

Enrollment Form

Travel Information

King's Kids Summer Day Camp

Enrollment Form

Release of Liability

PROGRAM FUNDING STATUS NOTICE

Transportation Plan and Authorization

PARENT TRANSPORTATION REQUEST FORM

Review and Submit