Program Applying For

Afterschool Summer Both

Date of Enrollment

Child's Name

Child's Date of Birth

Home Address

City

State

Zip Code

Home Phone #

Mother's Name

Father's Name

Mother's Workplace

Father's Workplace

Mother's Work Phone #

Father's Work Phone #

Mother's Cell #

Father's Cell #

Child Lives With

Family Email Address

I have received a read the handout regarding "Know Your Facility and Distracted Adult Handout". I hereby grant permission for the staff of this facility to have access to my child's records.

I accept and am responsible for abiding by the guidelines as outlined in the KIRM handout, which includes the discipline and expulsion policy and fee agreement.

I give permission for my child to attend scheduled KIRM activities, including those held away from regular site with the understanding that KIRM will inform me of scheduled activities and their location.

I will be responsible for transportation to/from activities/program. Transportation is provided for selective schools; please inquire. Transportation by bus will be by properly licensed drivers.

I understand my child must be picked up by closing time by a parent/guardian or adult listed on my pick up authorization form. Pick up after official close may result in a late fee per child. Late fees must be paid no later than Friday of the week that the late fee incurred.

I am responsible for abiding by the Fee Agreement as outlined in the handout. Fees are due by Friday prior to services provided but no later than Monday of the next week. Non-payment may result in a disruption of services and/or additional fees. No partial rates are available.

KIRM staff is authorized to obtain emergency medical treatment for the above named participant, as deemed necessary. However, KIRM holds no liability of incurred costs. KIRM does not administer any medication at any time to students.

KIRM has permission to post pictures of events on Facebook or flyers which includes my child.

Date

Signature of Parent/Guardian

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