Christmas Camp 2020 Registration Form
December Monday 21st, Tuesday 22nd, Wednesday 23rd, (KIA CLOSED THURSDAY 24th & 25th)
December Monday 28th, Tuesday 29th, Wednesday 30th, Thursday 31st (KIA CLOSED FRIDAY 1st)

Registration Fee: $25
Kids Day Out tuition rate is $227/ full time camp ($222/ with ACH form)
Kids Day out tuition rate is $190/ Camp only (9:30am-2:30pm)

Schooler kids Tuition rate is $222/week ($227 w/ Credit Card), or $55/day ($60 w/ credit card)

If registering after December 16th 2020, tuition will be $60/day ($65 w/ credit card). If you do not register prior to attending camp there will be a $15 late registration fee.

If you have any questions, please contact the office (281.358.9446 or kidsinactionfrontdesk@gmail.com).
Child's Full Name *
Child's Birth date *
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Child's Grade (grade school only)
My child will be enrolled in camp from: *
Second Child's Full Name
Second Child's Birth date
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Second Child's Grade (grade school only)
My child (second child) will be enrolled in camp from:
Clear selection
Third Child's Full Name
Third Child's Birth date
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DD
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Third Child's Grade (grade school only)
My child (third child) will be enrolled in camp from:
Clear selection
My child(ren) will be attending camp on: *
Required
Parent/Legal Guardian 1's Full Name *
Parent/Legal Guardian 1's relation to child *
Parent/Legal Guardian 1's Address (including city/zip) *
Parent/Legal Guardian 1's Cell Phone Number *
Parent/Legal Guardian 1's Cell Phone Provider *
Parent/Legal Guardian 1's Alternate Phone Number *
Parent/Legal Guardian 1's E-mail Address *
Is parent/legal guardian 1 authorized to pick up child? *
Parent/Legal Guardian 2's Full Name *
Parent/Legal Guardian 2's relation to child *
Parent/Legal Guardian 2's Address (including city/zip) *
Parent/Legal Guardian 2's Cell Phone Number *
Parent/Legal Guardian 2's Cell Phone Provider *
Parent/Legal Guardian 2's Alternate Phone Number *
Parent/Legal Guardian 2's E-mail Address *
Is parent/legal guardian 2 authorized to pick up child? *
Emergency Contact's Name (must be someone other than the child's parent/legal guardian) *
Emergency Contact's Address *
Emergency Contact's Relation to Child *
Emergency Contact's Phone Number *
Second Emergency Contact's Name (must be someone other than the child's parent/legal guardian)
Second Emergency Contact's Address
Second Emergency Contact's Relation to Child
Second Emergency Contact's Phone Number
Third Emergency Contact's Name (must be someone other than the child's parent/legal guardian)
Third Emergency Contact's Address
Third Emergency Contact's Relation to Child
Third Emergency Contact's Phone Number
My school-age child has permission to be released to the care of a sibling under 18 years old *
If you answered yes to the above questions, please provide the sibling's name, address, and phone number.
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. *
Doctor Name *
Doctor's Address *
Doctor's Phone 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 degrees, diarrhea, vomiting, any undiagnosed rash, or sore or discharging eyes or ears, or profuse nasal discharge. *
I understand that Kids in Action staff will only administer medication under the certain conditions: accompanied by a medication form that must be signed by the parent/legal guardian, all prescription medication must be in the original packaging and only if a physician has dispensed it with the student's name on it, and all medicine must be stored in locked, childproof containers (not in the child's backpack). *
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? *
List any known allergies or medications (allergy form must be completed and returned to be kept on file). *
Does your child have any special needs the staff needs to be aware of (ADD, Autism, Epi-Pen, speech, etc)? If so, please attach IEP. *
Please check all of the permissions that you agree to for your child(ren): *
Required
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 or obvious negligence by Kids in Action employees, I will not hold Kids in Action or its employees responsible. *
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. *
I have read and understand Kids in Action's policy on termination for cause. *
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 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 Friday 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 am aware that there will not be make ups or refunds. *
I understand that no space will be held without payment. *
I understand that all changes to the schedule must be done in writing to the front desk email (kidsinactionfrontdesk@gmail.com). The last day to make changes is Thursday, December 17th. After this date, I am responsible for paying for the schedule as is. *
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