Imagine Summer Program Application

IMAGINE Summer Program Registration

Early Registration Ends: April 30th $15 includes t-shirt. Each additional child is $8.
IMAGINE summer initiative is a 10 week summer fun-filled program that engages both the mind and body together to create a critical thinker. Making them focus on the tasks by using logic and nothing else. No electronics are allowed only their minds and community. We found it keeps the kids engaged and happy with crafts, foursquare, building robots, singing songs, 'recess', making sandcastles, kickball, making friends, laughing, and most importantly, they are so tired when its time to go... they have a great night sleep and never miss a day!

Two inspiring and innovative fun filled ideas running simultaneously... find out why we did it!

Participant Information
Summer Participant Information
Participant's Name*

First NameLast Name
Gender*

MaleFemale
Birth Date*

MonthDayYear
Grade last completed*
Child must have completed kindergarten to participate in Imagine Summer Program
T-Shirt Size*
Participant's Name*

First NameLast Name
Grade last completed*
Child must have completed kindergarten to participate in Imagine Summer Program
Gender*

MaleFemale
Birth Date*

MonthDayYear
T-Shirt Size*
Participant's Name*

First NameLast Name
Grade last completed*
Child must have completed kindergarten to participate in Imagine Summer Program
Gender*

MaleFemale
Birth Date*

MonthDayYear
T-Shirt Size*

Parent Information
Parent/Guardian Information
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home Number

Area CodePhone Number
Cell Number*

Area CodePhone Number
Can we text you*

Yes, all information about the programYes, only about my childNo
E-mail*

Emergency Information
Emergency Information
Emergency Contact's Name*

First NameLast Name
Relationship*
Phone Number*

Area CodePhone Number
Alt. Phone Number*

Area CodePhone Number
These People are Allowed to Pick Up My Child

Person picking up the child MUST have a STATE ID to verify who they are and Match the List. We CAN NOT accept text messages as an ID. NO EXCEPTIONS.
Pick Up Person One*

First NameLast Name
Pick up Person 2*

First NameLast Name
Pick Up Person 3*

First NameLast Name
Pick up Person 4*

First NameLast Name
Does child have any allergies, chronic illness, or medical conditions? If yes, please describe.
Please write N/A if not applicable to your child
Is your child prescribed an inhaler? If yes, please explain any instructions.
Informed Consent and Acknowledgement

I wish for the above minor child to be allowed to participant in or be a spectator at the activities sponsored by KC Society IMAGINE Summer Program and I give permission for the above mentioned child to go on trips away from the school facilities. I agree not to hold KC Society or any of its employees and/or volunteers responsible in any way for any accidents that may occur nor for any expensed which are incurred thereby. In case of a minor accident or illness I request KC Society to contact me and then any other family member who is eligible to pick up my child if I cannot be reached. If no contact can be made or there is an emergency situation I hereby authorize the staff of KC Society IMAGINE Summer Camp to make whatever arrangements they feel necessary for the health and well being of my child.

I hereby give my approval for my child’s participation in any and all activities prepared by KC Society during the Imagine Summer Program. In exchange for the acceptance of said child’s candidacy by KC Society ., I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless KC Society . and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected camp sessions.

In case of injury to said child, I hereby waive all claims against KC Society. including all coaches and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event. There is a risk of being injured that is inherent in all sports activities, including basketball. Some of these injuries include, but are not limited to, the risk of fractures, paralysis, or death.
Medical Release and Authorization

As Parent and/or Guardian of the named partipant(s) I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.

Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named athlete. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me.

Permission is also granted to KC Cosicety and its affiliates including Directors, Coaches, Employees and Volunteers to provide the needed emergency treatment prior to the child’s admission to the medical facility.

Release authorized on the dates and/or duration of the registered program.

This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child/children, in my absence.
Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Full Name*

First NameLast Name

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

IMAGINE Summer Program Registration