Summer Pass 2021 Registration

Thank you for your interest in Summer Pass 2021! Below you will find the required information for kids to participate in our programming. We have paper copies available as well if that's easier!

Week *

Summer Pass: 2nd - 5th grade

Summer Pass: 6-9th grade

Child's First Name *

Child's Last Name *

Birth Date *

YYYY

Gender *

Female

Male

Prefer not to say

Other:

School *

Dogwood Elementary

Hawthorne Elementary

Kearney Elementary

Southview Elementary

Kearney Middle School

Kearney Jr. High

Northern Hills Christian Academy

Elementary Outside of Kearney

Secondary Outside of Kearney

Home School

Other

Grade in Fall 2021 *

Number of Siblings

Favorite Pastimes

How did you hear about us? *

Child's T-shirt Size *

Youth Small

Youth Medium

Youth Large/Adult Small

Adult Medium

Adult Large

Street Address (City, State, Zip) *

Phone *

Parent/Guardian Email *

Parent / Guardian - Authorized to Pick Up

I authorize the following Parent/Guardian or Authorized Party to pick up my child from the Firehouse. I understand that if the persons named below are unable to pick up my child, I will provide a permission form to authorize another adult to pick up my child from the Firehouse.

~Parent/Guardian Information ~

Name *

Phone *

Alternate Phone *

~ Additional Adult Authorized to Pick Up ~

Name *

Relationship *

Phone *

Name

Relationship

Phone

Emergency Contacts

List individual(s) we may contact and/or release your child to in an emergency other than individuals already listed above.

Name *

Relationship *

Phone *

Name

Relationship

Phone

Medical & Behavioral Information

Physician's Name *

Physician's Phone *

Food Restrictions *

Allergies *

Please describe any medical, physical or behavioral information that may affect your child’s experience in the program. *

Parent/Guardian Consent

Please sign and date below on behalf of the child listed above, evidencing as their parent/guardian, permission and consent of the following:
• Permission to participate in supervised field trips that will be scheduled during program sessions. Field trips will be on foot and in close proximity to the Firehouse Community Center.
• Permission for the Firehouse to photograph me, and/or my children and to use any images thus obtained in their various publications for the promotion of the Firehouse and its programs.
• I hereby acknowledge that the Firehouse is not responsible for any lost or stolen personal property.
• As parent/guardian, I hereby give Firehouse permission to seek medical attention for my child in case of accident or emergency. I understand that every effort will be made by Firehouse staff to contact me and/or the emergency contacts in the event of a medical emergency. In the event of an emergency, if you or your emergency contact(s) cannot be reached, KEC staff will call 911.
• I understand and agree that by obtaining certain medical information about my child, Firehouse Community Center is not undertaking any obligation with respect to my child’s medical condition or treatment.
• I understand and agree that if my child is injured or causes injury to others during or in connection with participation in any Firehouse program, I hereby release, indemnify and will hold harmless Kearney Enrichment Council, the Firehouse Community Center, its employees, agents, trustees, instructors, and volunteers from any and all claims arising out of any such injuries.

Signature *

I am interested in being a Summer Pass Volunteer *

Yes for Week 1- July 5-9

Yes for Week 2 - July 12-16

Required

Today's Date *

YYYY

Submit

Never submit passwords through Google Forms.

This form was created inside of Kearney Enrichment Council. Report Abuse

Forms