2019 CFK Application - Lycoming College for Kids & Teens
Please fill out this form to register your child(ren) for the 2019 annual Lycoming College for Kids & Teens summer program. If you are enrolling more than one child, please use the form for one enrollment only. After you have completed the form and submitted it for the first child, refresh the page (Shift and Refresh) for a new, blank application form.

Payment is made separately, and all classes are filled on a first-come, first-served basis. Children are enrolled in their first choice class, when possible. Class size is limited and classes close quickly, so be sure you select a second choice.

Classes are held July 22-26, 2019 at Lycoming College.

This form also contains important PERMISSION FORMS - the FIELD TRIP FORM and the MODEL RELEASE FORM. Please type the name of the PARENT in this section, since you are giving your permission for your child.

You will receive an automatic email confirmation of this form submission.

Last Name of Child: *
Your answer
First Name of Child: *
Your answer
Street Address: *
Your answer
City: *
Your answer
State *
Your answer
Zipcode *
Your answer
Parent 1 Name: (This is the person registering the child) *
Your answer
Parent 1 Email: (This is the person receiving the form notification) *
Your answer
Parent 1 Phone (Best Contact -- Mobile) *
If one phone number is used for Home, Work and Mobile, please enter it again
Your answer
Parent 1 Phone (Second Best Contact) *
If one phone number is used for Home, Work and Mobile, please enter it again
Your answer
Parent 2 Name: (If you wish; good backup)
Your answer
Parent 2 Email:
Your answer
Parent 2 Phone (Best Contact Phone)
Your answer
Parent 2 Phone (Second Best Contact)
Your answer
Emergency Contact Name *
Your answer
Emergency Contact Phone Number *
Your answer
Child's School: *
Your answer
Grade Completed as of June, 2018: *
Required
Child’s T-shirt size: *
First Period -- Class Choice:
Choose your child's first choice of class for First Period (9 a.m.-Noon)
Second Period -- Class Choice:
Choose your child's first choice of class for Second Period (Noon-4 p.m.)
Full-Day College for Teens
Junior Assistant with College for Kids* (by invitation only)
Medical, Allergy & Food Intolerance Notes *
List any medical conditions or allergies we need to be aware of during College for Kids week:
Your answer
Field Trip Release Form *
By typing the PARENT NAME below, you give permission for your child to take short field trips with the class. In consideration of being permitted to participate in various field trips with College for Kids and Teens, I the undersigned, in full recognition and appreciation of the dangers and hazards inherent in a trip and during transportation to and from Lycoming College, do hereby agree to assume all the risks and responsibilities surrounding my participation in the activities undertaken by my child. As an adjunct thereto; and, further I do for myself, my heirs, and personal representatives hereby defend, hold harmless, indemnify and release Lycoming College and forever discharge any and all its officers, agents and employees from and against any and all claims, demands, and actions or causes of action, on account of damage to personal property, or personal injury, or death which may result during the period of my child’s participation. My child will abide by all state laws and act in a manner suitable to represent Lycoming College.I acknowledge that while the College will make every reasonable effort to minimize exposure to known risks, all stresses and hazards associated with this activity cannot be foreseen. My child has a personal responsibility to follow safety rules and procedures established by College for Kids leaders and will make them aware at any point in which participation in the activity is questionable.
Your answer
Release Form (for photos during program) *
By typing PARENT NAME below I hereby grant the following rights and permissions to Lycoming College ("Photographer"), its legal representatives and assigns, those for whom Photographer is acting, and those acting with Lycoming College’s authority and permission. They have the absolute right and permission to take, use, reuse, publish, and republish photographic portraits or pictures of the minor or in which the minor may be included, in whole or in part, or composite or distorted in character or form, without restriction as to changes or alterations from time to time, in conjunction with the minor's own or a fictitious name, or reproductions of such photographs in color or otherwise, made through any medium at Photographer's studios or elsewhere, and in any and all media now or hereafter known, including the internet, for art, advertising, trade, or any other purpose whatsoever. I also consent to the use of any published matter in conjunction with such photographs. I waive any right that I or the minor may have to inspect or approve any finished product or products or the advertising copy or printed matter that may be used in connection with such photographs or the use to which it may be applied. I understand that the images of the minor may be used in advertisements to promote Lycoming College or any of its various programs. Knowing that such uses may intentionally or unintentionally give rise to the impression that the minor participates in said program, I nevertheless consent to this use. I release, discharge, and agree to hold harmless and defend the Photographer, Lycoming College or its legal representatives or assigns, and all persons acting under the college’s permission or authority or those for whom he/she is acting, from any liability by virtue of any reason in connection with the making and use of such photographs, including blurring, distortion, alteration, optical illusion, or use in composite form, whether intentional or otherwise, that may occur or be produced in the taking of said picture or in any subsequent processing thereof, as well as any publication of them, including without limitation any claims for libel or violation of any right of publicity or privacy. I hereby warrant that I am a legal competent adult and a parent or legally appointed guardian of the minor, and that I have every right to contract for the minor in the above regard. I state further that I have read the above authorization, release, and agreement, prior to its execution, and that I am fully familiar with the contents of it. This release shall be binding upon the minor and me, and our respective heirs, legal representatives, and assigns.
Your answer
Lunch *
My child will do one of the following for lunch
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