Enrollment Application for Kids' Adventure Club
Please complete this form if you want to submit an application for the upcoming school year. **Submitting this form does not guarantee a slot for your child.**
Child's Full Name
*
First Name
Last Name
Application Date
*
-
Month
-
Day
Year
Date
Child's Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Child's Birthdate
*
-
Month
-
Day
Year
Date
Gender
*
Grade
*
Please Select
K
1
2
3
4
5
6
Other
Home School
*
Please Select
Carder
Erwin Valley
Gregg
Severn
Smith
Winfield
CPP Middle School
Other
Program (Choose all that apply)
*
Summer
School Year
Morning Care
Afternoon Care
Program Year
*
(ie. 2026-2027)
Do you have or have you previously had a child enrolled in KAC or any other Pathways, Inc. program?
*
Yes
No
Name of Child Previously Enrolled
Name of Person Applying for Child
*
First Name
Last Name
Relationship to Child
*
(ie. mother, father, guardian)
Address (if different than child)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Employer
*
Primary Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Secondary Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Additional Parent/Guardian Name
First Name
Last Name
Relationship to Child
(ie. mother, father, guardian)
Address (if different than child)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Employer
Primary Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Secondary Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Emergency Contacts
Please include three other adults who may pick up your child from the program without a note and who you grant permission to be a contact for emergencies if you are not available. Please list in the order that you would like them contacted.
Emergency Contact Name #1
*
First Name
Last Name
Relationship to the Child
*
(ie. sister, grandparent, uncle)
Primary Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Secondary Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Name #2
*
First Name
Last Name
Relationship to the Child
*
Primary Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Secondary Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Name #3
*
First Name
Last Name
Relationship to Child
Primary Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Secondary Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
SUBMIT
Should be Empty: