2025 Summer Program Registration

SUMMER PROGRAM REGISTRATION FORM

(319) 213-7644 | [email protected]

1. Youth Information

* Indicates required field

Child’s Full Name *

D.O.B. *

Age: *

Grade completed (as of this summer) *

School Currently Attending: *

Has your son or daughter participated in JKM summer programming? *

Is your son or daughter currently participating in JKM after school programming? *

Is your son or daughter planning on attending summer school? *

If yes, what is the school they will be attending? *

What is the address to the summer school they will be attending? *

What time will your child be dismissed from summer school? *

Will your child need transportation to and from JKM? *

If yes, what is your pick-up/ drop off location? *

Will you be dropping your child off at JKM? *

*All pick-ups will be at area recreation centers- Conway, Maplewood, Arlington, McDonough*

2. Parent/Guardian Information

Parent/Guardian Full Name(s): *

Relationship with Youth: *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Email: *

Primary Phone Number: *

Secondary Phone: *

3. Parent/Guardian 2/Non-custodial Parent (If Applicable)

Parent/Guardian Full Name(s): *

Relationship with Youth: *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Email: *

Primary Phone Number: *

Secondary Phone: *

4. Emergency Contacts and Authorized Pick-up Persons (Not Parents/Guardians)

Full Name: *

Relationship with Youth: *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Email: *

Primary Phone Number: *

Secondary Phone: *

Please List the names and relationships to those you authorize to pick up your son or daughter: *

Anyone authorized must show an ID when picking up youth.

5. Medical Information

Does the youth have any allergies? *

Yes No

If Yes, please specify: *

Does the youth take any medications? *

Yes No

If yes, please specify: *

Does your child have any medical conditions or special needs we should be aware of? *

Yes No

If yes, please list. *

6. Signature and Authorization

By signing below, I hereby affirm that I am the parent or legal guardian of the youth named in this registration form. I certify that all the information provided herein is accurate and complete to the best of my knowledge. I acknowledge and agree with the following:
I authorize The JK Movement and its representatives to obtain any necessary medical treatment for the youth in the event of an emergency when I cannot be reached. I understand that participation in The JK Movement Summer Program involves certain inherent
risks, and I voluntarily assume full responsibility for any risks of loss, property damage, or personal injury that may be sustained by the youth because of participation. I release and hold harmless The JK Movement, its staff, affiliates, officers, volunteers, and agents from any and all liability, claims, or demands arising from or related to participation in the program. I give permission for photographs, video recordings, and other media of the youth to be taken during the program for educational or promotional use by The JK Movement, unless otherwise stated in writing. I understand that it is my responsibility to notify The JK Movement in writing of any changes to the information provided on this form.

Parent/Guardian Printed Name: *

Signature: *

Date: *

Submit

​2025 Summer Program Registration

SUMMER PROGRAM REGISTRATION FORM

​The JK Movement

Subscribe Form

2025 Summer Program Registration

The JK Movement