Junior Pet Care Summer Camp Waitlist

Kid's Summer Camp at Kirkwood Learning Center Waitlist

Please provide all of the information in this form. This must be completed in order for your child to attend the Kennelwood Summer Camp. Please fill out a separate Form Response for each minor that is attending. Each sibling will need a separate form filled out. You will only need to fill out one (1) form, per minor. Class registration will not be processed if any information or signatures are missing. Please read carefully Please email Jenny Dove at [email protected] with any questions!

Registrant's Name(Required)

First Last

Registrant Date of Birth(Required)

MM slash DD slash YYYY

Camp Selection

Camp Selection(Required)

Please select the camp(s) you child will be attending. All camps are 8am – 12pm Monday through Friday.

Parent / Guardian Information

Parent / Legal Guardian's Name(Required)

Parent / Legal Guardian's Email(Required)

Parent / Legal Guardian's Cell Phone Number(Required)

Parent / Legal Guardian's Home/Work Phone Number(Required)

Would you like to list a second parent / guardian ?

Yes

Parent / Legal Guardian's Name(Required)

Parent / Legal Guardian's Email(Required)

Parent / Legal Guardian's Cell Phone Number(Required)

Parent / Legal Guardian's Home/Work Phone Number(Required)

Adults Authorized for Pick-Up

You will be required to sign your child in/out every day. For your child's safety, we require a list of persons allowed to pick up your child. Please note, a child can only be released from class to the adult(s) authorized for pick-up below. A valid photo-ID will be required to confirm this information at pick-up. Please list anyone who is authorized to pick up your child from camp. These will also be used as alternative contacts in case of emergency and we are unable to reach the parents/guardians first.

First & Last Name(Required)

Phone Number(Required)

Relationship to Child(Required)

Would you like to authorize an additional adult?

Yes

First & Last Name(Required)

Phone Number(Required)

Relationship to Child(Required)

Would you like to authorize an additional adult?

Yes

First & Last Name(Required)

Phone Number(Required)

Relationship to Child(Required)

Allergies

Please indicate below if your child has a food allergy. Please indicate N/A if your child has no known food allergy (note: that children will be using peanut butter in a class activity)

Please list allergy information:(Required)

I acknowledge that:(Required)

Children will be around pets and dander during this summer camp

Medication Administration

If your child carries an epi-pen for a food allergy, or requires medication to be on hand during class hours for a medical condition, this must be noted below in order for your child to attend class. You are responsible for bringing the epi-pen/medication to the class leader at sign-in each day of camp that your child attends. Medications will be stored out of reach of children during camp hours. The child must be able to administer meds on their own. Please indicate N/A if this section is not applicable to your child.

Please note any medications required to be on hand for your child:(Required)

Parent/Guardian Authorization

Kennelwood Activity Waiver and Release
Kids Camp Information Doc

Please checkmark the boxes below acknowledging your understanding.

I verify that to the best of my knowledge that everything on the Adult Authorized Pick Up Form is correct and the child herein is in good health.

He/She has no physical ailments that will prevent normal participation unless specified on this form.

He/She has my permission to participate in the Kennelwood program(s).

I recognize that failure to disclose, falsification or deliberate omission of information will result in termination of the ability for the child herein to participate in the Kennelwood Kids Camp.

I understand that in the event of an emergency, my child will be taken to the closest hospital.

I accept responsibility for the charges incurred from transportation, medical or surgical treatment.

I understand should my child be suspended/dismissed from the Kennelwood Kids Camp due to behavioral issues, Kennelwood will NOT prorate the class balance and I will be responsible for the full amount.

All information I have provided at the time of enrollment is complete and accurate.

I understand that I am committing to participation in the Kennelwood Kids Camp.

I understand that when my child is ill it is understood and agreed that he/she may not be accepted to the Kennelwood Kids Camp.

I understand that my child will not be released to any person(s) not listed on the Authorized Pick Up Form.

I understand that my child must be signed in & out daily by myself or my designee (as listed on the Authorized Pick Up Form).

Kennelwood reserves the right to terminate services if it is determined that the placement is unsatisfactory.

I understand that photographs will be taken throughout the Kennelwood Kids Camp. These pictures may be displayed in Kennelwood’s advertisements and/or marketing materials, including social media. If I do not want my child's picture taken, I understand it is my responsibility to notify the Kennelwood class leader.

I have received, read and agree to abide by all the policies and procedures as outlined in the Kids Camp Informational Document.

I understand that I am financially responsible for services.

Signature(Required)

Please sign to acknowledge you have reviewed and agree with the Kennelwood Activity Waiver and Release, as well as the Kids Camp Information Doc

Upload a Photo

This photo will be used as part of an activity during the camp week. If you need time to find a photo you can skip this section and email a photo, the week prior to your child’s camp start date, to [email protected]

File

Accepted file types: png, jpeg, jpg, Max. file size: 100 MB.

Kid's Summer Camp at Kirkwood Learning Center Waitlist

Camp Selection

Parent / Guardian Information

Adults Authorized for Pick-Up

Allergies

Medication Administration

Parent/Guardian Authorization

Upload a Photo

Other Questions / Comments

Stay Pup-To-Date

Junior Pet Care Summer Camp Waitlist

Kid's Summer Camp at Kirkwood Learning Center Waitlist

Camp Selection

Parent / Guardian Information

Adults Authorized for Pick-Up

Allergies

Medication Administration

Parent/Guardian Authorization

Upload a Photo

Other Questions / Comments

Stay Pup-To-Date

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