Last name: / First Name: / Preferred Name:
Current address:
City: / State: / ZIP Code:
Date of birth: / Age of child on 9/1/2016 / Male / Female
Family years at KOK: / Siblings Names:
Does your child have separation issues, if so please explain:
Does your child have allergies and / or medical concerns?
Please list allergies and / or medical concerns:
Allergy Action Plan will be required before the first day of camp if none on file.
FAMILY INFORMATION
Father/ Guardian Name:
Dad's email: / Cell Phone:
Dad's employer: / Business Phone:
Mother / Guardian's Name:
Mom's Email: / Cell Phone:
Mom's Employer: / Business Phone:
Church affiliate:
Check Weeks Attending: / Theme:
$25 reg $100 / Week 1 June 19-22 / Under the Sea
$25 reg $100 / Week 2 June 26-29 / Around the World
$25 reg
$100 / Week 3 July 10-13 / Stars and Stripes, Sports
$25reg $100 / Week 4 July 17-20 / Under the Big Tent Circus
$25 reg $100 / Week 5 August 7-10 / Mad Science
$25 reg
$100 / Week 6 August 14-17 / Camping Under the Stars
A THREE-WEEK CANCELLATION NOTICE IS REQUIRED FOR A REFUND.
PLEASE BRING A SNACK, LUNCH AND DRINK EVERYDAY
PIZZA DAY WILL BE THURSDAY!! COST IS INCLUDED IN CAMP FEE.
AUTHORIZED PEOPLE TO PICK UP YOUR CHILD AND EMERGENCY CONTACT (OTHER THAN PARENTS)
Name: / Relationship: / Phone: / Cell:Address:
Name: / Relationship: / Phone: / Cell:
Address:
Name: / Relationship: / Phone: / Cell:
Address:
Medical Information
Child’s Doctor: / Phone:Insurance: / Phone:
Policy / group Numbers:
FIRST AID PERMISSION
Please check BOTH BOXES if we have your permission to apply first aid cream or anti-itch cream if needed for your child
Permission to apply ointment/first aid cream
Permission to apply anti-itch/hydrocortisone cream
FOOD PERMISSION
My child has permission to participate in food activities
My child may not participate in food activities
My child may participate in food activities with exception to the following foods due to allergies:
PHOTO RELEASE FORM
REQUIRED INFORMATION
Please check yes or no below if your child’s photo can be used.
Yes NO
School publications (newsletters, bulletin boards, photo albums, etc) Preschool/Church websites.
No names will be uses
SIGNATURES
Kids of the Kingdom Learning Center will provide first aid and take appropriate measures including contacting the emergency medical services (EMS) system. Kids of the Kingdom Learning Center will arrange for emergency transportation to Memorial Hermann Northeast in Humble or the nearest emergency medical facility, if necessary. At no time, will a staff member drive with my child unless accompanied by another adult. My child will be transported by an ambulance or other such vehicle if necessary.
I understand that no emergency treatment may be given without parental consent, except in a life-threatening situation. I hereby authorize Kids of the Kingdom to follow this procedure.
Parent Signature: Date: