(Updated) Summer Camp Registration Form

Family information
Parent 1 Name

First NameLast Name
Parent 1 Cell Number

Area CodePhone Number
Parent 1 Employer
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent 1 Work Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent 1 Work Number

Area CodePhone Number
E-mail
example@example.com
Parent is authorized to pick-up child
Parent 2 Name

First NameLast Name
Parent 2 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent 2 Cell Phone

Area CodePhone Number
Parent 2 Employer
Parent 2 Work Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent 2 Work Number

Area CodePhone Number
Parent 2 Email
example@example.com
Parent is authorized to pick-up child

Child information

Rows	Child's Name	Birthdate	Gender	Child's Grade for 2026-2027 school year	Child's shirt size
Child 1 Name
Child 2 Name
Child 3 Name
Child 4 Name

Select your child's dates

**please note that once the form is submitted, your dates are final and you are financially responsible for the dates that you have chosen.
What will Child 1's first date of admission be?
Select the weeks Child 1 will be attending:
Which program will Child 1 be enrolling in? You may select more than one option (for children who turn 3 or 5 years old during the summer months):
What will Child 2's first date of admission be?
Select the weeks Child 2 will be attending:
Which program will Child 2 be enrolling in? You may select more than one option (for children who turn 3 or 5 years old during the summer months):
What will Child 3's first date of admission be?
Select the weeks Child 3 will be attending:
Which program will Child 3 be enrolling in? You may select more than one option (for children who turn 3 or 5 years old during the summer months):
What will Child 4's first date of admission be?
Select the weeks Child 4 will be attending:
Which program will Child 4 be enrolling in? You may select more than one option (for children who turn 3 or 5 years old during the summer months):
School AGE ONLY: My child attends the following school and his/her immunization record is on file at the school and all required immunization test are current. Vision and hearing screening records are also on file.
Other school if not listed above (school address and phone number)

Emergency Contacts and Authorized pick ups (must provide address and contact number)

Rows	Full Name	Address	Contact Number	Relationship
1
2
3.
4.

I give permission to receive periodic text messages in case of emergencies and/or school closures
I understand that I am financially responsible for tuition for the weeks I sign up for, if I do not give a full 2 week notice in writing upon withdrawal.
I understand that activity fees will be charged at time of registration per child and are non-refundable regardless of attendance. A secure link will be sent out after registration to get payment information if not already on file.
My child has permission to be released to the care of a sibling under the age of 18 years old.
If yes to the previous question, please list the siblings name(s).
Emergency Medical care: I authorize Kids in Action, in an emergency, to act in my behalf for my child's sake and to have my child transported to the nearest medical facility at the parent's expense.
Child's pediatrician Name
Child's Pediatrician Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Child's Pediatrician Phone Number

Area CodePhone Number
I understand that I may not bring my child to Kids in Action when he/she is exhibiting any of the following: a temperature of over 100, 3 or more bouts of diarrhea or vomiting, any undiagnosed rash, or sore, or discharging eyes or ears, or profuse nasal discharge. If my child is sent home, they must remain out a minimum of 24 hours and cannot return until they a symptom free and unmedicated for at least 24 hours.
I understand that Kids in Action staff will only administer medication under the certain conditions: 1. Only if your child needs 3 or more doses and Kids in Action will administer the middle dose only. The only exception is if the medication needs to be taken at a certain exact time, such as ADD medication. 2. Medicine is accompanied by a medication form that must be signed by the parent/legal guardian (available upon request at the front desk).
List any and all previous illnesses, broken bones, surgeries, etc.
Are there any restrictions on normal activities? If so, please explain.
Is your child physically and mentally able to participate in group activities?
Is your child free from infection and contagious disease?
I understand that there is always some risk of injury due to accident while children are playing together and that unless any injury is a direct result of abuse of obvious negligence by Kids in Action employees, I will not hold Kids in Action or its employees responsible.
Does your child have any special needs the staff needs to be aware of (ADD, Autism, Epi-pen, speech, etc)? If so, please send a copy of the child's IEP.
List any known allergies or medications (allergy form must be completed and returned to be kept on file).

Please check all of the permissions that you agree to for your child(ren):

Rows	Yes	No	N/A
play and participate in all on-site activities
play on the outdoor playground/slack line (age appriate)
watch movies at the center that staff select (rated G or PG)
play video games that are age appropriate
participate in water activities (water table, sprinkler play, splashing or wading pools water hoses, water slides and slip and slide)
I acknowledge that my child must be 100% potty trained in order to participate in swimming or water slide activities.
swimming in swimming pools and aquatic playgrounds w/certified lifeguard on duty (schoolers group only)
participate in Archery (school groups only)
participate in Razor drifting trike activities(school group ONLY)
participate in Ninja Warrior and Nerf Wars (school groups only)
Have KIA bug spray/sunscreen applied as needed (NO-AD SPF 50 & Cutter Sensations w DEET) required unless we have doctors note
I give my permission for my child(ren) to be transported to and from field trips specified on the field trip form given prior to the first field trip (school groups only)
My child has permission to be transported to and from Showbiz Cinema in the event of a field trip cancellation. There will be 24 hours notice (school groups only)

I give consent for my child to participate in the following water activities. Check all that apply.

The following questions are for school age children:

Rows	Yes	No	Does not apply (my child is not school aged)
Is your child able to swim without assistance? (If no, your child is required to wear a life jacket while in or near a swimming pool)
Does your child have any physical, health, behavioral or other condition that would put them at risk while swimming? (If yes, your child is required to wear a life jacket while in or near a swimming pool)
Would you like to request that your child be required to wear a life jacket while in or near a swimming pool?

I understand that my swimmer must pass a swim test based on the following definition of a competent swimmer: "A competent swimmer can enter and exit a pool safely on their own, tread water or float on their back for one minute, and swim 25 yards with no assistance" **school age children only** (please type your name or "does not apply")

I have read and understand Kids in Action's policy on discipline and guidance

Rows	Yes
Discipline must be: individualized and consistent for each child, appropriate to the child's level of understanding, and directed toward teaching the child acceptable behavior and self control
A care giver may only use positive methods of discipline and guidance that encourages self-esteem, self-control, and self-direction which include at least the following: using praise and encouragement of acceptable behavior instead of focusing on unacceptable behavior, redirecting behavior using positive statements, reminding children of behavior expectations daily using clear and positive statements, and using brief supervised separation or time out from the group, when appropriate for the child's age and development, which is limited to no more that one minute per each year of the child's age
There must be NO harsh, cruel or unusual treatment of any child. The following types of discipline and guidance are PROHIBITED: corporal punishment or threats of corporal punishment, punishment associated with food, pinching, shaking or biting a child, hitting a child with a hand or instrument, putting anything in or on a child's mouth, humiliating, ridiculing, rejecting or yelling at a child, subjecting a child to harsh, abusive or profane language, placing a child in a locked or dark room, bathroom or closet with the door closed, and requiring a child to remain silent or inactive for inappropriately long periods of time for the child's age
All of the above are in accordance with Texas Administration code, title 42, chapter 746-747, subchapters L, discipline & guidance.

I have read and understand Kids in Action's policy on termination for cause.

Rows	Yes
Children: bullying, defacing and/or destroying center property or the property of others, engaging in aggressive behavior toward other children and/or staff members including, but not limited to: spitting, yelling, hitting, kicking. being rude and/or discourteous to any staff member, using foul language on the premises, stealing from the center, staff or other children, refusing to remain with assigned group, horse playing in the swimming pool or on a field trip
Parents: engaging in aggressive behavior toward a child and/or staff member of the center, failure to call if child's schedule changes that affect drop off/pick up from school, failure to follow check in/out procedures, using foul language on the premises, being rude and/or discourteous to any staff member, failure to provide the necessary enrollment forms and/or information to the center, and failure to pay accurate and current fees. All fees are due the Monday before the following camp week. Any fee not paid by the 2nd day following the scheduled payment day, will be charged a late fee payment of $15. NO EXCEPTIONS

I understand that my child may participate in Outdoor Curriculum and will: get muddy(please wear appropriate clothes on classroom's day), be tasting veggies/fruits/herbs that they grow, will be engaging in more risky play (moving rocks, building with sticks; playing in the rain, utilizing hammers and garden tools for certain activities, handling bugs, being around bees. (Please type your name in acknowledgement)
I consent to my child’s photo being taken, shared with me so we can see what's going on throughout the day, and used in school advertising or promotional materials (please type your name in acknowledgement).
I understand that I will need to complete the online summer orientation that will be emailed to me. At this orientation, I will be informed on the following items: discipline and guidance, procedures for release of children, suspensions and expulsion, illness and exclusion criteria, emergency plans, procedures for dispensing medications, procedures for conducting health checks, immunization requirements for children, safe sleep, meals and food service practices, procedures for parents to discuss concerns with the director, procedures to visit the center without securing prior approval, promotion of indoor and outdoor physical activity, procedures for supporting inclusive services, criteria for extreme weather conditions, procedures for parents to participate in operation activities, and procedures for parents to contact Child Care Regulation (CCR), DFPS, Child Abuse Hotline and CCR website (please type your name in acknowledgement).
By typing my name below I acknowledge and agree that all information is true. I agree to abide by the policies listed in this form.
Please upload a clear picture(s) of your child(ren) so we can add it to their account (you can upload more than one picture for multiple children):

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Please upload a signed copy of your child's immunization records (Infant-Pre-K only. If school age child, upload a blank document). This cannot be a download from MyChart-must be signed by the physician.

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Camp Tuition agreement
Payment for my child's program is due on MONDAY of the current week. Tuition is due whether my child attends or not. All accounts must by set up on automatic payment plan for tuition. A $10/day late fee will be added if not paid by the end of business on Monday. If tuition and/or late fees are not paid by Wednesday, then I understand that my child cannot return to care until paid. A $10/per week discount will be given to all accounts who use a checking/savings account for auto charge payment (please type your name)

INCLEMENT WEATHER, PANDEMIC OR OTHER RELATED CLOSINGS: Kids in Action follows Humble ISD closings. Please check local TV stations and web sites for announcement of closing. Full tuition is due during inclement weather times. If extended circumstances exist, such as a flood or pandemic, where the center is closed for an extended amount of time, then the following tuition policy will apply

Rows	Please check each box below
INCLEMENT WEATHER, PANDEMIC OR OTHER RELATED CLOSINGS: Kids in Action follows Humble ISD closings. Please check local TV stations and web sites for announcement of closing. Full tuition is due during inclement weather times. If extended circumstances exist, such as a flood or pandemic, where the center is closed for an extended amount of time, then the following tuition policy will apply
After 3 weeks, 50% tuition will be due until the child returns
If you choose to withdraw your child, a 2-week notice and full tuition is required. After 2-weeks, your child’s spot will not be held, and a new registration fee will be required to re-enroll, if openings remain.

If Kids in Action is closed, and children are unable to attend, then the following tuition schedule applied

Rows	Please check each box below
Full tuition is due for 3 weeks following the closure
50% tuition will be deducted for 3 weeks following
After 6 weeks of closure, no tuition will be collected, and the children’s spots will be held
In case of serious emergencies such as earthquakes, fire, storms, or loss of power/water, parents will be notified, if possible, and children will be cared for until parents or emergency contacts arrive.

In the event of a NSF check/ACH return, a $35 penalty fee will be added to my account. If Kids in Action receives 3 or more NSF checks/ACH returns in one year, your enrollment may be terminated (please type your name).
Kids in Action is licensed by The Texas Department of Family and Protective Services. Operating hours are Monday-Friday from 6:30 am to 6:30 pm, and we can only care for children during these specified times. A late fee of $10 for the first 10 minutes, and an additional $1 per minute will be charged to your account (please type your name).
In the event your child forgets his/her KIA t-shirt on a field trip day, a $15 charge will be applied to your account (please type your name).
Proper attendance tracking is imperative to the safety of the children enrolled. All parents are required to sign their children in and out each day. When a family fails to sign their child in or out, a $5 penalty fee will be applied to your account for each occurrence (please type your name).
If at any point my account becomes delinquent, I understand that any credits or discounts will be removed from my account (multiple child discount, First Responders, etc.) (please type your name).
Kids In Action chooses not to get involved in custody disputes. In the event a court order is on file, Kids In Action will not acknowledge which party is responsible for payment of tuition fees. These arrangements must be coordinated between the two parents. Late fees and withdraw guidelines will still apply regardless of which parent is responsible for tuition fees (please type your name).
All tuition payments are payments to hold the child's space in the program. Tuition is due regardless of attendance. (please type your name)
If at any point my account becomes delinquent, I understand that any credits or discounts will be removed from my account (multiple child discount, First Responders, etc.) (please type your name)
If I choose to end my relationship with Kids in Action and withdraw my child, a 2-week notice will be given in writing. I understand that I am financially responsible for tuition if I do not give a full 2 week notice in writing upon withdrawal (please type your name)
I understand that the activity fees (per child) are due upon registration and are non-refundable regardless of attendance. A secure link will be sent out after registration to get payment information if not already on file. (please type your name)
Payment

Activity fees are due upon registration and are non-refundable regardless of attendance. A secure link will be sent out after registration is complete to get payment information if not already on file.
Activity/Registration fees:

Infant, Waddler, Older Toddler (new families) - $115

Pre-school 3's (all families/per child) - $230

Pre-school 4's (all families/per child) - $235

School-age/KinderPrep (Kinder-5th grade/per child) - $335
Weekly Tuition fees:

Early Education -
- Infant - $377/week
- Waddler - $361/week
- Older Toddler - $356/week
Pre-school -
- Pre-school 3's - $336/week
- Pre-school 4's - $331/week
Schoole age/KinderPrep (Kinder-5th grade for the 2026-2027 school year) - $300/week

**Discounted tuition $10/week for ACH (listed prices are if using a credit card)
I understand the above activity and tuition fees. (please type your name)
How did you hear about us?
Should be Empty:

Family information

Select your child's dates

Camp Tuition agreement

Payment