Kicks With Christ Application Form
Kicks with Christ is an afterschool program located at Calvary Baptist Church (915 Cherokee Rd, Florence, SC 29501). KWC will operate in conjunction with the school calendar of Florence School District One. The times of operation will be Mondays-Fridays from 2:15pm - 5:45pm (except for Wednesdays, when pick up will be 5:15pm). This program's enrollment will be capped at 30 participants. Enrollment per child is $60/week, which will be collected every Friday. Transportation can also be provided for $40/month.
Child's First Name *
Your answer
Child's Last Name *
Your answer
What name does the child like to be called? *
Your answer
Street Address *
Your answer
City *
Your answer
State *
Your answer
Zip *
Your answer
Mailing Address *
Your answer
City *
Your answer
State *
Your answer
Zip *
Your answer
Male or Female *
Birth Date *
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DD
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YYYY
Age *
Grade *
Your answer
School *
Your answer
T-shirt size *
Child in the custody of/lives with *
Parent/Guardian #1- First Name, Last Name *
Your answer
Parent/Guardian #1-Relationship to Child *
Your answer
Parent/Guardian #1 - Home Address (Including City, State, Zip Code) *
Your answer
Parent/Guardian #1 - Place of Employment *
Your answer
Parent/Guardian #1 - Home Phone # *
Your answer
Parent/Guardian #1 - Mobile Phone #
Your answer
Parent/Guardian #1 - Email Address *
Your answer
Parent/Guardian #2 - First Name, Last Name *
Your answer
Parent/Guardian #2 - Relationship to Child
Your answer
Parent/Guardian #2 - Home Address (Including City, State, and Zip Code)
Your answer
Parent/Guardian #2 - Place of Employment
Your answer
Parent/Guardian #2 - Home Phone #
Your answer
Parent/Guardian #2 - Mobile Phone #
Your answer
Parent/Guardian #2 - Email Address
Your answer
Additional Pick Up #1. Please indicate who else is authorized to pick up your child (must be 18 years or older). Include the information in this format: First Name, Last Name, Relationship to Child, Home/Mobile Phone Number. If no one else is authorized, please type N/A. *
Your answer
Additional Pick Up #2. Please indicate who else is authorized to pick up your child (must be 18 years or older). Include the information in this format: First Name, Last Name, Relationship to Child, Home/Mobile Phone Number. If no one else is authorized, please type N/A. *
Your answer
Child's Medical Information: Immunization Records. Immunization Records are REQUIRED for all children to participate in the Kicks With Christ program. Your child may not begin with Kicks For Christ until current immunization records are received. These can be sent to: 1318 Madison Avenue, Florence, SC 29501 or emailed to KicksWithChrist@gmail.com. *
Child's Medical Information: Primary Care Physician (Name, Practice Name, Office Phone #, Address, City, State, Zip)
Your answer
Child's Medical Information: In case of an emergency, please check the hospital you prefer we use: *
Required
Child's Medical Information: Please check any box that applies to your child. You will have an opportunity to provide additional information on the next question. *
Required
Please explain why you checked boxes on the previous question.
Your answer
Allergy Information. Please check any that apply. *
Required
Please explain why you checked boxes on the previous question.
Your answer
Health Information. Please check any that apply. You will have an opportunity to provide additional information with the next question. *
Required
Please provide any additional information you would like us to know.
Your answer
Please specify what the reactions will be if the above allergies occur and procedures we should follow:
Your answer
Is your child currently taking medications? *
Will Kicks With Christ need to administer the medication to your child? If yes, we will have you complete an additional form.
I understand that there is a $80 registration fee associated with this program. The $80 will also cover the first week of my child's enrollment with Kicks With Christ and a KWC t-shirt. A check will need to be made out to Kicks With Christ, LLC and mailed to 1318 Madison Avenue, Florence, SC 29501. *
Required
I understand that the enrollment cost of my student's participation with Kicks With Christ is $60/week. Payments are due each Friday. Failure to pay on time will result in the removal from the KWC program. *
I understand that Kicks With Christ will follow the 10 month school calendar of Florence School District One. *
Will your child need transportation from their school to KWC? (Transportation will be conducted by Bee Helpful. This will be an additional $10/week.) *
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