Kids Connection Fall Registration

Emergency Contact Information
Safety is a top priority at Kids Connection. A security card will be needed to enter the church to pick up your child. List below all who will be using the cards assigned to your family. (Note: The names that appear below must be 16 years old or older.)

Please list three emergency contacts that we may contact in the event of an emergency. These people will also act as authorized adults to pick up you child.
Pickup Name 1*

First NameLast Name
Phone Number

Area CodePhone Number
Relationship
Pickup Name 2

First NameLast Name
Phone Number

Area CodePhone Number
Relationship
Pickup Name 3

First NameLast Name
Phone Number

Area CodePhone Number
Relationship

Transportation Agreement
I am the parent or guardian of the undersigned child. I hereby authorize Plainfield United Methodist Church and/or Kids Connection (the “Organization”) to transport my child to and from any of the Organization’s activities (the “Transportation”) and I hereby release and waive any claims against the Organization, its organizers, directors, officers and volunteers arising from the Transportation. To the extent any claims are asserted against the Organization relating to the Transportation, I agree to indemnify and hold the Organization harmless from and against any and all liabilities, losses, damages, expenses and claims of any kind including reasonable attorneys’ fees. This waiver applies even though said liability may arise out of negligence or carelessness on the part of the Organization, except that I will have no obligation to indemnify the Organization to the extent that any claim of a third party arises solely from the intentional and willful misconduct of the Organization. This document shall be binding upon my heirs, representatives, successors and assigns and shall be construed in accordance with the laws of the State of Indiana. If any provision in this document is held to be unenforceable, it is agreed that the remaining provisions hereof shall continue in full force and effect.
Transportation Agreement*

I agree to the above Transportation Agreement
My child needs to ride in a booster seat:*

YesNo

Program Information
Registration Fee: $100 per child.

Tuition: Tuition is due at the beginning of the 15th of the month. Payment can be in cash or a check brought to Kids Connection (Room 210) or mailed to Kids Connection, 600 Simmons Street, Plainfield 46168.

Tuition is paid for the month(s) your child is enrolled - whether or not your child attends the entire month(s).

Each family will be issued a security card to enter the building. Only people authorized to pick up your child should use this card. There is a $10 fee for lost cards.
Please check the appropriate program(s)*

Morning Only - 6:30am-8:30amAfternoon Only - 3:50pm-6pmBoth Morning and Afternoon

We would like to use pictures of the Kids Connection students in brochures, and on the church website and Facebook page. We will not include students’ names or any other information.
Consent for use of picture(s)*

Yes, you may use my child’s picture in this way.No, you may NOT use my child’s picture in this way.
I understand that I will be notified of {childsName} acceptance into the KIDS@PUMC Kids Connection Program via email.

Upon {childsName} acceptance to the KIDS@PUMC Kids Connection program, I agree to pay a NON-REFUNDABLE registration fee in the Kids Connection office (Room 210) before 6:00 pm the next business day to hold my child's place.

Please make checks payable to Kids Connection.
Signature*
Type your full name
Date

MonthDayYear
Date
Should be Empty:

Parent/Guardian Information