King’s Elementary School 19531 Dayton Avenue N.

Shoreline, WA 98133

Phone: (206) 546-7595

Fax: (206) 546-7586

Father | Step-Father

Guardian

Mother | Step-Mother

Guardian

2019 King’s Kids Club (KKC) SummerBreak Day Camp Registration Form

King’s Kids Club provides daily care over the summer with weekly themes, features and field trips in addition to the same engaging

KIDS Praise, arts and crafts, games, and educational activities that kids enjoy during our school year before and after school program.

KKC serves kids entering Kindergarten through Sixth Grade students.

Please complete a form for each child, sign, and return to King’s Elementary School office

Student Information Please circle student’s T-shirt size (free): Youth-S Y-M Y-L Adult-S A-M A-L

Name Gender Birthdate Grade Entering (K-6) Enrolled at King’s?

Parent/Guardian Information

Name Circle Address, City, State, Zip

Name Circle Address, City, State, Zip

Primary Phone Number Primary E-mail Address

2019 SummerBreak Day Camp Options Day Camp Hours are 8:00am – 5:00pm

Weekly Rates

4-5 days per week* $290

2-3 days per week $200

1 day per week $80

Weekly Half-Days Mornings (8:00am-12:30pm) or Afternoons (12:30pm-5:00pm)

$180

Daily Before and After Extended Care Available Before (7:00am – 8:00am) | After (5:00pm – 6:00pm) Pre-registration not required

$10.50/hour

Daily Breakfast and Lunch Available, pre-registration not required $2.75 | $4.50 per meal

Please mark the sessions and days of the week that your child will be attending. Note “½-am” or “½-pm” if you are registering for a weekly half-day session. Your child must be registered by Monday at 12:00pm, of the camp session week, to attend the field trips scheduled for the week.

o 1. June 17-21: Taking Flight

o 2. June 24-28: Sports Fan-tastic!

o 3. July 1-5: Gamers

o 4. July 8-12: Down on the Farm

o 5. July 15-19: Island Adventures

o 6. July 22-26: Space Exploration

o 7. Jul 29-Aug 2: The Great Outdoors

o 8. August 5-9: Extreme Sports

o 9. August 12-16: Animal Kingdom

o 10. August 19-23: Superheroes

Mon ____ Tue ____ Wed ____ Thu ____ Fri ____ $_______

Mon ____ Tue ____ Wed ____ Thu ____ Fri ____ $_______

Mon ____ Tue ____ Wed ____ Thu closed Fri ____ $_______ Mon ____ Tue ____ Wed ____ Thu ____ Fri ____ $_______

Mon FULL Tue FULL Wed FULL Thu FULL Fri FULL $FULL Mon FULL Tue FULL Wed FULL Thu FULL Fri FULL $FULL Mon FULL Tue FULL Wed FULL Thu FULL Fri FULL $FULL Mon FULL Tue FULL Wed FULL Thu FULL Fri FULL $FULL Mon ____ Tue ____ Wed ____ Thu ____ Fri ____ $_______

Mon FULL Tue FULL Wed FULL Thu FULL Fri FULL $FULL $100 non-refundable Registration Fee ($50 for 2nd/multi-child or if registered before May 17th) $ 50 | 100

I understand I will be billed for the sessions selected above and am aware of KKC’s refund policy. Total $________ *For full summer package pricing contact us at KKC.SummerCamps@kingsschools.org

OFFICE USE ONLY

Reviewed by/Date:

Notes:

Page 2

KKC: 2019 SummerBreak Day Camp Registration Form Terms and Conditions

Inspiring hearts and equipping minds to serve God for His glory

DROP OFF AND PICKUP PROCEDURES: All campers must be signed-in when arriving for the day and signed-out when departing. A

parent’s/guardian’s failure to sign-out a camper may result in billing through 6:00pm. Any Camper remaining past the 6:00pm closing time will

be assessed a “Late Pick-up Fee” of $10.00 for the first 15 minutes and $5.00 for each additional five minutes. Campers may only be picked

up by parents or previously approved substitutes who are 18 years of age or older.

BILLING:

King’s Families – All charges indicated on the registration form will be billed and paid through your Smart Tuition account with your

monthly invoices unless prepaid or otherwise arranged.

Non-King’s Families – Prepayment is required for the registration fee and weekly session rates. Extended care and meal fees should be

remitted at the beginning of each weekly session.

CANCELLATIONS AND REFUNDS: For cancellations, we require a written notice two weeks prior to the start of the session OR one-half

session’s fee in lieu of notice. Refunds for cancellations will first be applied to future unpaid SummerBreak camp sessions. If no balance exists for

future camp sessions, a refund will be processed through our Accounting Department and may take 2-3 weeks for receipt. Your enrollment fee is

non-refundable.

DELINQUENT ACCOUNTS: Payments received after the scheduled due date are delinquent. A $40 follow up fee will be added to delinquent accounts and a 1% finance charge may be assessed on balances not paid by the due date. Campers may not attend if the account is 45 days past due. A $25 fee will be

assessed for returned checks and declined auto-debit transactions. Should King’s be required to retain legal counsel to enforce the terms of this Agreement

in any way, including but not limited to collections, garnishments, litigation or any other method permissible by law, you agree that King’s shall be entitled to recover from you all of its legal fees and costs including fees and costs incurred in any post judgment collections, appeals, mediations and bankruptcy

proceedings.

BEHAVIORAL GUIDELINES: Families must abide by all policies and guidelines of the School including, but not limited to, the Handbook for Parents & Students, and the KKC SummerBreak Day Camp Procedures. Parents are expected to help their children understand and follow all guidelines.

SummerBreak Day Camp does not discriminate in the admission of Campers based on race, color, national origin, sex, age, or disability or any other

protected class status as governed by federal and state law.

HEALTH/ILLNESS GUIDELINES: Parents will report any serious or infectious illnesses to the KKC Director immediately. Campers must not attend

KKC if showing signs of a serious cold or other communicable disease. (Children with a temperature of 100 degrees or more will not be accepted for care.

Furthermore, a child who is too sick to go outside is too sick to come to KKC.) If my child becomes ill while at KKC, I agree to pick him/her up myself or

send an authorized person immediately. Children must be on medication for 24 hours before returning to KKC if medication is prescribed by a physician.

ARBITRATION: Except in the case of collections, all disputes related to this Agreement or enrollment at the School shall be resolved by binding

arbitration. The parties may agree to mediate prior to arbitration in accordance with the following terms. Mediation and arbitration shall be before a mutually acceptable person who: (1) is a practicing attorney with a minimum of ten years’ experience or a retired judge, and (2) agrees with the CRISTA Ministries

doctrinal statement. In the event that the parties cannot agree on such a person, each shall appoint a qualified person and the two shall agree on a third

qualified person to be the sole mediator or arbitrator. The arbitrator need not be the same person as the mediator. The parties hereby incorporate, and the

arbitration shall follow, the procedures of Chapter 7.04 RCW. Additionally, the arbitrator shall have the authority to order such discovery, by way of

deposition, interrogatories, document production, or otherwise, as the arbitrator considers necessary to full and fair exploration of the issues consistent with

the expedited nature of arbitration. The laws of the State of Washington shall govern. The parties shall evenly split the costs of both mediation and

arbitration.

WAIVER, RELEASE, ASSUMPTION OF RISKS & INDEMNIFICATION: I, the parent or legal guardian of ____________(“Camper”), agree as

follows: I acknowledge and understand that certain activities, including but not limited to, use of playground equipment, field trips and other KKC activities, can be hazardous and may result in injury, including loss of life. I voluntarily assume any and all risks of loss, damage or injury while Camper is on the

premises. In consideration for Camper’s participation, I represent that I am the parent or legal guardian and hereby release and forever discharge CRISTA

Ministries, King’s Schools, King’s Kids Club and their servants, employees, officers, directors, trustees and all other persons or entities acting on their behalf (collectively referred to as “CRISTA”), from any and all claims, actions, damages, liabilities, costs or expenses and attorney fees which are related to, arise

out of, or are in any way connected Camper’s viewing or participation in any activities. By signing this Agreement, it is my intention to waive any rights I

may otherwise have to sue or seek damages from CRISTA; except where injury, death or disability results from CRISTA’s gross negligence.

I further agree to indemnify, hold harmless and defend CRISTA against any and all claims for damages, costs, expenses or attorneys fees brought

by any third party in connection with or arising out of Camper’s involvement or participation. Moreover, in consideration for Camper’s

participation in activities, including the use of equipment and facilities, I further agree to indemnify and hold CRISTA harmless from any and all

claims which are brought by, or on behalf of Camper and which are in any way connected with such use or participation by Camper. This

Agreement shall be effective and binding upon my marital community, estate, heirs, agents, personal representatives and assigns.

EMERGENCY CONSENT: _____________________ (Camper’s name) may receive emergency or routine medical care from a licensed physician or emergency facility if I cannot be reached in an emergency situation. Such emergency or routine care includes emergency surgery, administration of

medications or other measures as determined necessary by a licensed physician. I agree to assume the responsibility for all medical, transportation and

rescue-related expenses incurred on behalf of Camper.

PHOTO RELEASE: CRISTA may publish photos taken of Camper and I release all rights to remuneration for such photos. Yes____ No_____

I hereby certify that I am over 18 years of age; I have carefully read the foregoing and acknowledge that I understand and agree to all the terms and

conditions. I have had the opportunity to ask any and all questions regarding this Agreement and the effect of the same. I am aware that by signing

this Agreement, I assume all risks, agree to indemnify CRISTA and waive and release certain rights that I may otherwise have. Handwritten

changes to the language of this document are not permitted and will not be honored. This Agreement constitutes the entire Agreement and shall not

be modified except via written document, executed by both parties.

Parent/Guardian Signature Date

Page 3

King’s Kids Club (206) 546-7595 King’s Elementary (206) 546-7258 Policy Number K.12.

KING’S SCHOOLS POLICY/PROCEDURE

Student Excursion Permission and Release Summer 2019

For use with any school sponsored and school supervised activity involving the transportation of students.

Name of activity: KING’S KIDS CLUB/SummerBreak Day Camp 2019 ON/OFF CAMPUS LEARNING TRIPS Date(s) of tentative activities: June 17, 2019 to August 23, 2019

Week 1: 6/18 – Boeing Factory in Everett, 6/20 – The Museum of Flight

Week 2: 6/25 – Traxx Indoor Go-Kart Racing, 6/27 – T-Mobile Park (Mariners) Field Tour & Spin Alley Bowling

Week 3: 7/2 – Family Fun Center (Tukwila)

Week 4: 7/9 – Carnation Farms, 7/11 – Remlinger Farms

Week 5: 7/16 – Seattle Aquarium, 7/18 – Jetty Island

Week 6: 7/23 – The Space Needle, 7/25 – Pacific Science Center & IMAX

Week 7: 7/30 – Discovery Park, 8/1 – Wallace Falls State Park

Week 8: 8/6 – Vertical Rock Climbing, 8/8 – Northwest Trek Wildlife Park & Zipline

Week 9: 8/13 – Woodland Park Zoo, 8/15 – Point Defiance Zoo

Week 10: 8/20 – The Flying Circus, 8/22 – iFly

I hereby do _______ do not _______ give permission for ___________________________________________ to be taken on the field trips or activities listed above, or their alternative destination in case of field trip location cancellation, using King’s authorized transportation. The school’s secondary coverage student insurance plan will cover your child according to the guidelines as outlined in the Parent Handbook. For questions or further information, call the elementary school office listed above.

Parent/Guardian Signature ___________________________________________ Date _________________

CONSENT FOR RELEASE OF MEDICAL INFORMATION AND MEDICAL TREATMENT CONSENT

In the event of any medical emergency involving my child __________________________________________, I _____________________________________ as his or her parent or legal guardian, hereby grant authority, and consent to the King’s Schools/CRISTA Ministries staff to administer or arrange for reasonable medical care for my child in the event that I cannot be contacted in time by reasonable means. In a medical emergency, I further consent and grant authority to a physician, nurse or other appropriate health care provider to render whatever emergency care they deem necessary for my child.

I hereby release King’s Schools and CRISTA Ministries, their employees, directors and agents from any liability, and agree to hold them harmless for any expense (medical, ambulance, etc.), arising out of their reasonable efforts to provide such emergency medical care for my child.

I further agree to take sole financial responsibility for any medical services rendered to my child and hereby grant to the King’s Schools employee supervising the above activity a special power of attorney to arrange for such reasonable medical services.

X ________________________________________ X _________________________ SIGNATURE of Parent/Guardian Date

X ________________________________________ X _______________________________ PRINTED NAME of Parent/Guardian Relationship to Student

Page 4

STUDENT EMERGENCY FORM Summer 2019 Grade Teacher

Child’s name Last First Middle

Birthdate Name (Nickname) Used)

Mom’s email:__________________________________ Dad’s email: ____________________________________

□ Okay to give out email address

Parent/Guardian Information

Mr/Dr______________________________________ Employer___________________________________ Work phone ( ) - Cell phone ( ) -

Mrs/Ms/Dr____________________________________ Employer______________________________________ Work phone ( ) - Cell phone ( ) -

Home phone # ( ) -

Street address City, State Zip Code

Co-Custodial/Non-Custodial Information

Mr/Dr_____________________________________ Employer___________________________________ Work phone ( ) - Cell phone ( ) - Home phone ( ) -

Mrs/Ms/Dr___________________________________ Employer____________________________________ Work phone ( ) - Cell phone ( ) - Home phone ( ) -

Street address City, State Zip Code

Emergency Contact Numbers (must have address & phone numbers)

Name Address Telephone number Name Relationship Home ( ) -

Cell ( ) -

Name Relationship Home ( ) - Cell ( ) -

Name Relationship Home ( ) - Cell ( ) -

Out of State Family Member Name Relationship

Home ( ) - Cell ( ) -

Persons Authorized to Pick Up Child from School/KKC (must have address & phone number)

Name Relationship Home ( ) - Cell ( ) -

Name Relationship Home ( ) - Cell ( ) -

Name Relationship Home ( ) - Cell ( ) -

Siblings attending King’s Schools Name Grade Name Grade

Name Grade Name Grade

Who does NOT have permission to pick up your child (A copy of supporting court document must be on file.)

Name Reason

Name Reason

Parent/Guardian Signature

Relationship Date

Please complete Health & Medical Information on the back.

Page 5

Child’s Health Information

Date of child’s last physical exam

Child’s Healthcare Provider Telephone number ( ) -

Address City, State Zip Code

Child’s Dentist’s Name

Telephone number ( ) -

Address City, State Zip Code

*If any allergies or asthma, an *Individualized Plan signed by doctor must accompany *Medication to Administer Form.

*Special health problems? Yes or No? If yes, specify:

*Allergies, include drug reactions? Yes or No? If yes, specify:

*Regular Medications? Yes or No? If yes, please specify:

Other important information? Yes or No? If yes, specify:

Child’s Medical Insurance Coverage

Insurance company name

Member/Policy number

Policy holder name

Employer name

Insurance company name

Member/Policy Name

Policy holder name

Employer name

Consent to Medical Care and Treatment of Minor Child

I give permission that my child, ______________________________, may be given first aid/emergency treatment by King’s Elementary School and King’s Kids Club located at 19531 Dayton Ave N. Shoreline, WA 98133.

Parent/guardian Signature

Date Parent/guardian Signature

Date

When I cannot be contacted, I authorize and consent to medical, surgical, and hospital care, treatment, and procedures to be performed for my child by a licensed physician, healthcare provider, hospital or aid care attendant when deemed necessary or advisable by the physician or aid care attendant to safeguard my child’s health. I waive my right of informed consent to such treatment. I also give my permission for my child to be transported by ambulance or aid car to an emergency center for treatment. I certify under penalty of perjury under the laws of the State of Washington that this information is true and correct. Parent/guardian Signature

Date Parent/guardian Signature

Date

CONFIDENTIALITY WILL BE HONORED!

Thank you for assisting us in providing the best care for your child.

Page 6

King’s Kids Club (KKC) SummerBreak Day Camp Guideline and Procedures

Parental Acknowledgement 2019

Our guidelines and procedure are put in place to protect and care for the children who attend SummerBreak. We appreciate your

support in carry out these practices. Please initial after reading each statement to acknowledge that you have read and understand

the KKC policy.

1. Children must be registered by 12:00pm/noon on Monday to attend the field trips scheduled for the camp week. We cannot reasonably

accommodate late additions for field trips after the Monday, noon deadline. _____

2. All kids must have completed permission slips and medical forms turned in prior to field trip attendance. Children who do not have signed permission slips and completed medical forms for field trips will stay at King’s with staff and not be allowed to attend field trips. ______

3. Kids wear summer break camp t-shirts for Tuesday and Thursday field trips. Each child will be given a t-shirt on Monday when they check-out. If a child forgets to wear their t-shirt for a field trip, they will receive a new shirt and the parents will be charged $15.00. ______

4. Every child should bring a refillable water bottle daily to keep with them during daily activities to stay hydrated. ______

5. We are a nut free zone. Please do not send your child to camp with any nut products as this creates a liability for children with allergies. ______

6. Electronic devices and toys are not allowed at camp. If students are caught with electronics or toys they will be given to the desk staff, kept until the child’s check out time, and given to the parent. _______

7. SummerBreak Day Camp follows King’s Elementary dress standards: No tank tops, sleeveless, or backless shirts, low cut tops, flip flops or shoes without backs. For water days/beach students need to arrive with their water wear packed in a bag. Flip flops can be worn on water/beach days for the water/beach activity only and must remain in the child’s bag at other times. Tennis shoes are preferred for all daily activities. ______

8. On Fridays, we will be outside for 2 ½ hours during water day. In addition, kids are outside for recess and activities on a daily basis. We do not apply sunscreen on children. Please apply sunscreen daily to your children before you drop them off or send them with sunscreen to apply themselves. ______

9. Parents/guardians must show their photo ID at pick-up. If someone who is not on the approved pick up list attempts to pick-up a child, the parent(s) must be called to get verbal confirmation of the arrangement. In all cases, the person picking up the child must show a photo ID. If you need to make pick-up changes please email us or call us in advance. KKC.SummerCamps@kingsschools.org; 206-546-7595. _____

10. Summer camp hours are from 7:00am – 6:00pm. Structured activities are from 8:30am – 4:30pm. All children must be signed in and signed out by an adult. Children may not check themselves in our out. Failure to sign out your children will result in billing through 6:00pm. _____

11. Breakfast and lunch are available for purchase daily. Snacks are included in your camp fee. _____

12. Children who are throwing up or who have fevers should stay home. If your child throws up at camp or has a fever over 99, you will be called to pick them up. ______

13. To dispense medication we must have medicine in the original bottle/container and completed medical approval forms signed by the child’s doctor and parent/guardian(s). _____

14. Cancellations & Refunds: For full refund we require 2 weeks written notice prior to the start of the session. Notice given after 2 weeks to the day before the session start date will result in ½ fee refund. There will be no refunds for cancellations received on or after the first day of the weekly camp session. _____

15. Behavior: Children are given 2 warnings before being sent to the KKC director. After the director speaks with the child, they are sent back to

camp activities. If negative behavior continues, the parent is called to intervene and/or pick up the child; depending on the circumstance. If a child

physically harms another child or staff member, the parent will be called and asked to pick up their child. There are no refunds in disciplinary cases.

_____

________________________________________ ______________________ Parent/Guardian Signature Date

Page 7

Approved Pick-up Form

Please complete and return this form if there will be someone other than the

parent/guardian(s) listed on the child’s registration picking up at the end of the day.

Child’s/Children’s Name(s): _______________________________________________________

______________________________________________________________________________

Parent’s/Guardian’s Name: _______________________________________________________

Parent’s/Guardian’s Phone Number: _____________________________

The following are able to pick up the above listed child/children:

Name Relationship Phone Number

Child(ren) will not be released to anyone not listed above without prior written or verbal consent

from parent/guardian(s). If someone who is not on this list attempts to pick up your child, you

will receive a phone call. Those picking up kids must show photo IDs to King’s staff at pick up

time, without exception.

________________________________________ __________________ Parent/Guardian Signature Date