KPS Education Initiative

KPS Education Initiative

The KPS Education Initiative provides curricular and extracurricular programming designed to advance academic achievement, social-emotional development, and college/career readiness. By submitting this Enrollment & Consent Form, the undersigned authorizes participation in Initiative activities, agrees to the financial and conduct terms set forth below, and certifies the accuracy of the information provided.

Student Information

Date of Birth:    Student ID:    Grade/Program:

Parent / Guardian Information (If Student is Under 18)

Relationship to Student:    Primary Phone:    Email:

Program Enrollment Details

Program Start Date:    Program End Date:    Location:

Tuition Amount: $    Payment Plan: One-time payment Monthly installments

Emergency Contact & Medical Information

Relationship:    Phone:

Medication Authorization: I authorize Initiative staff to administer or supervise prescription medications as specified in written instructions from a licensed prescriber and to seek emergency medical care if necessary.

Consents, Acknowledgments & Program Policies

Assumption of Risk and Release: By checking the box below, the undersigned acknowledges that participation in Initiative activities may involve inherent risks. The undersigned agrees to release and hold harmless KPS Education Initiative, its employees, volunteers, and agents from liability for bodily injury, property damage, or other loss to the fullest extent permitted by law, arising from participation, except to the extent caused by gross negligence or willful misconduct.

I acknowledge and accept the Assumption of Risk and Release provision.

Tuition, Fees, Cancellation and Refunds: Tuition obligations arise upon enrollment confirmation. Cancellations received in writing at least 14 days prior to the program start date qualify for a full refund less any non-refundable deposit. Cancellations less than 14 days prior to program start are eligible for a partial refund per Initiative policy. The undersigned remains financially responsible for outstanding tuition and any collection costs for unpaid balances.

I agree to the Tuition, Fees, Cancellation and Refunds policy and accept financial responsibility for enrolled tuition.

Student Records and Privacy: The Initiative will maintain records necessary for program administration. Student information will be used for program operations, safety, assessment, and limited reporting to affiliated educational partners. The Initiative will take reasonable measures to protect personal data. The undersigned authorizes the Initiative to collect and use the information provided for these purposes.

I consent to collection and use of student information as described above.

Media and Promotion Release: I authorize the Initiative to photograph, record, or otherwise document the participant and to use such media for program promotion, educational materials, and reporting. No compensation is due for such use. If consent is not given, check the opt-out box.

I consent to media use as described above.    I do NOT consent to media use.

Student Conduct and Discipline: The undersigned agrees that the student will adhere to Initiative rules, safety protocols, and code of conduct. The Initiative reserves the right to remove a participant whose behavior endangers others or materially disrupts programming, subject to any applicable procedural rights.

I have read and agree to the Student Conduct and Discipline provisions.

Additional Administrative Information

Certification: I certify that the information provided on this form is true and complete to the best of my knowledge. I understand that intentional misrepresentation may result in denial of enrollment or dismissal from the Initiative and that I remain responsible for any financial obligations incurred prior to such action.

I certify the information provided is true and complete.

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