Student Kidscreate Form

Student Kidscreate Form

Student Information

Date of Birth:    Student ID:

Parent / Guardian Information

Program Selection & Schedule

Program Enrolled:

Program Start Date:

Medical & Emergency Information

Permissions & Consents

Please check each box to indicate consent where applicable:

I authorize program staff to obtain emergency medical treatment for the student if parents/guardians cannot be reached. I understand reasonable attempts will be made to contact listed emergency contacts prior to non-emergent treatment.

I authorize program staff to administer non-prescription medications or my child's prescribed medications as described in writing and consistent with program policies. Any medication to be administered must be provided in original labeled container with written instructions.

I grant the program permission to photograph or record the student for educational, promotional, or archival use. I understand images or recordings may be used in printed materials, social media, or internal publications without additional consent.

I give permission for the student to participate in supervised local outings and field trips as part of the program. I understand specific trip details will be provided in advance and additional consent may be requested for off-site transport.

I authorize the student to be transported by program staff/approved contractors for program activities when necessary. I acknowledge that drivers and vehicles will meet program safety requirements.

Tuition, Fees & Payment Authorization

Program Fee Amount: $

I authorize automatic charging of the indicated payment method for scheduled program fees according to the payment plan above and acknowledge applicable late fees or collection costs for non-payment.

Policies, Acknowledgments, and Waiver

By signing below, I acknowledge that I have read and agree to the program rules and safety procedures provided by the program. I understand that participation requires compliance with attendance, behavior, and safety policies; persistent noncompliance may result in dismissal without refund.

Liability Waiver: Except for willful misconduct or gross negligence by program staff, I release and hold harmless the program, its employees, volunteers, and agents from claims, liabilities, and expenses arising from ordinary risks associated with program participation. This release includes claims for property damage, personal injury, and other losses arising from participation.

Cancellation and Refunds: Program fees may be refundable in whole or part only in accordance with the program's cancellation policy. Refund amounts, deadlines, and administrative fees are governed by program terms disclosed at enrollment.

Privacy & Data Use

Administrative Use of Data: The program will collect and maintain student records necessary for administration, safety, and billing. Personal information will be shared only with authorized staff, emergency responders, and persons listed on this form as permitted. Records will be retained in accordance with program policy.

Certification

I certify under penalty of perjury that the information provided on this form is true and complete to the best of my knowledge. I understand that falsification of material information may result in enrollment termination and forfeiture of fees. I have authority to enroll and consent for the student named on this form.

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