Christ The King Lutheran Church - KOK Summer Camp 2023

First Name

Last Name

Preferred Name

Address 1

Address 2

City

State

Zip/Postal Code

Date of Birth

Age of Child on 9.1.2022

Gender

Sibling names and Ages

Child Lives With:

Custody Documents on File
Yes
No

Church Affiliation

Does your child have any allergies or food allergies? If yes, please explain.
Yes
No

Child Food allergies:

FARE Plan Submitted

Emergency Medication

Does your child have any special needs, illnesses, or medical concerns? If yes, please explain and include any supporting documents or information (email documents to tonib@christ4u.net) to help us best care for your child.

FAMILY INFORMATION

Mother/Guardian Name

Cell Phone

Mom/Guardian Email

Mom/Guardian Employer

Business Phone

Father/Guardian's Name

Cell Phone

Dad/Guardian Email

Dad/Guardian Employer

Business Phone

AUTHORZIED PEOPLE TO PICK UP YOUR CHILD AND EMERGENCY CONTACT (OTHER THAN PARENTS)

KOK will only release children to a parent/guardian or to a person designated by the parent/guardian after verification of ID. I give permission for KOK staff to release my child to an authorized person below without contacting me in advance.

Parent Printed Name:

Parent Signature. (By typing your name you authorize this as your signature)

Today's Date

Please mark which dates you would you like your child to attend. Fees are NON-REFUNDABLE. All available spaces are filled on a first come, first served basis and waiting lists will begin as soon as a class has filled. All KOK Summer Camp classes may cancel for inadequate enrollment. Age requirements by 9/1/2022: MDO 18 months; Preschool 3’s - 3yrs. old/Toilet Trained; Preschool 4’s - 4 yrs. old/Toilet Trained

Summer Camp Dates
June 12-15 / 9am-2pm / Weekly Cost $140
June 19-22 / 9am-2pm / Weekly Cost $140
June 26-29 / 9am-2pm / Weekly Cost $140
July 10-13 / 9am-2pm / Weekly Cost $140
July 17-20 / 9am-2pm / Weekly Cost $140

Authorized people:

Name

Relationship

Phone

Cell Phone

Address

Name

Relationship

Phone

Cell Phone

Address

Name

Relationship

Phone

Cell Phone

Address

MEDICAL INFORMATION

Child's Doctor

Phone

Insurance

Insurance Phone Number

Policy/Group Numbers

GENERAL PERMISSION - PLEASE READ EACH SECTION AND SELECT YES OR NO

My child may participate in water table play activities
Yes
No

FOOD PERMISSION

I understand that KOK does not serve meals and I will provide lunch and snack for my child daily. KOK is not responsible for the nutritional value of the food or for meeting my child's daily food needs.
Yes

My child has permission to participate in food activities
Yes
No

My child has a food allergy, and I must be contacted prior to any food activities.
Yes
No

EMERGENCY CARE

Kids of the Kingdom will provide first aid and take appropriate measures including contacting the emergency medical services (EMS) system. Kids of the Kingdom 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 (by typing your name you authorize this as your signature)

Today's Date

*KIDS OF THE KINGDOM accepts cash, check, and bright wheel electronic payments. KIDS OF THE KINGDOM offers the following discounts: $ 50.00 when booking all 5 weeks of camp.

We do not have online payment for this form. To pay for registration please select one of the following choices
Check
Cash
Sign up on Brightwheel for Credit Card Payment ( we will send you an invite for our school )

Kids of the Kingdom Summer Camp 2023

FAMILY INFORMATION

AUTHORZIED PEOPLE TO PICK UP YOUR CHILD AND EMERGENCY CONTACT (OTHER THAN PARENTS)

Authorized people:

MEDICAL INFORMATION

GENERAL PERMISSION - PLEASE READ EACH SECTION AND SELECT YES OR NO

FOOD PERMISSION

EMERGENCY CARE

Service Times

Contact Info

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