Rising Kings & Queens Summer Program Registration

Rising Kings & Queens Summer Program Registration

Complete this form to enroll your child in the summer program and provide necessary information.
Student Information
Student Full Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Age
Grade Entering in Fall 2026
Current School
Gender
T-Shirt Size
Parent / Guardian Information
Parent / Guardian Full Name

First NameMiddle NameLast Name
Relationship to Child
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Preferred Method of Contact
Emergency Contact
Emergency Contact Name

First NameLast Name
Relationship to Child
Primary Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Alternate Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Authorized Pick-Up Persons
Authorized Pick-Up Persons
Is anyone prohibited from picking up this child?
Explain any prohibited pick-up restrictions
Upload supporting documentation, if applicable

Cancelof
If there are no restrictions, select No. If there are restrictions, provide details and upload any applicable documentation.
Health and Safety Information
Allergies
Medications
Medical Conditions
Dietary Restrictions
Physical Limitations
Behavioral, Emotional, or Learning Supports Needed
Reading Literacy Information
Does the child enjoy reading?
Does the child need help with reading?
Current reading level, if known
Areas of concern

Other
Favorite books, characters, or topics
Parent literacy goals for this child this summer
Program Interest Areas
Reading Literacy
Music
Dance
Drama
Spoken Word
Fitness
Etiquette
Financial Literacy
Leadership
Career Exploration
Mentoring
Arts and Creativity
Permissions and Releases
Photo and video release
Transportation permission for off-site trips

Not applicable
Emergency medical permission
Permission to participate in fitness and recreation activities
Permission to receive snacks and meals

Will provide my own snacks/meals
Parent or guardian agreement to program rules
Code of Conduct Agreement
Conduct Agreement Statement
Parent/Guardian Signature
Student Signature
Date

MonthDayYear
Date
Family Support Needs
Food assistance resources
Clothing assistance resources
Housing support resources
Utility assistance resources
Mentoring resources
Counseling or referral resources
School supplies resources
Transportation resources
Final Registration Agreement
Please confirm that Rising Kings & Queens Summer Program is free of charge, space is limited, and that you agree to notify House of David if your child can no longer attend so the spot may be offered to another family.
Parent / Guardian Printed Name

First NameLast Name
Parent / Guardian Signature
Date

MonthDayYear
Date
Should be Empty:

Rising Kings & Queens Summer Program Registration

Student Information

Parent / Guardian Information

Emergency Contact

Authorized Pick-Up Persons

Health and Safety Information

Reading Literacy Information

Program Interest Areas

Permissions and Releases

Code of Conduct Agreement

Family Support Needs

Final Registration Agreement