KROKA EXPEDITIONS

Kroka Community School-Spring Semester

Mon Jan 18 - Fri Jun 4, 2021 (138 days)

AGES: 12 - 16

TRANSLATE THIS FORM: Español, Português, Tiếng Việt, Tagalog, Kreyòl ayisyen

FOR WHOM?

I AM A PARENT OR GUARDIAN
REGISTERING A NEW CHILD/MINOR TO PARTICIPATE

I AM A RETURNING PARENT OR GUARDIAN:

OUR FAMILY or HOUSEHOLD HAS REGISTERED FOR OTHER PROGRAM ACTIVITIES WITHIN THE PAST 3 YEARS

YOUR (PARENT/GUARDIAN) NAME:

YOUR (PARENT/GUARDIAN) CONTACT INFORMATION:

NAME:

CONTACT INFORMATION:

BIRTHDATE:

Please enter a valid birthdate here...

GENDER:

Please enter a gender information here...

use button or write in anything!

Male

Female

Non-Binary

PRONOUNS:

use button or write in anything!

He/Him/His

She/Her/Hers

They/Them/Theirs

BACK

HOUSEHOLD/FAMILY DETAILS:

PARTICIPANT MAILING ADDRESS:

* ONLY IF OUTSIDE OF USA

YOU MAY ENTER ONE OR TWO RELATED ADULTS
WHO LIVE or WORK AT THIS ADDRESS:

ADULT #1

(optional)

parent, step-parent, guardian, spouse, etc.

(optional)

ADULT #2

(optional)

parent, step-parent,
guardian, spouse, etc.

(optional)

I WANT TO INCLUDE ANOTHER ADULT/PARENT/GUARDIAN AT A DIFFERENT ADDRESS

SUBMIT ADULT CONTACT INFORMATION

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PERSONAL INTRODUCTION

What specifically interests you in this program?
What other interests / hobbies / activities do you enjoy?

What specifically interests your child in this program?
What other interests / hobbies / activities do they currently enjoy?

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IMPORTANT DETAILS:

DIET:

NONE

Please describe any special dietary restrictions, and indicate whether they result from personal preference, religious custom, or medical necessity.

ALLERGIES:

NONE

Any ALLERGIES?
To foods? To medications? To insect stings or other environmental agents?
If so, please explain the symptoms and the severity of these allergies: ( MILD DISCOMFORT or SEVERE LIFE THREATENING ANAPHYLAXIS )

MEDICATIONS:

NONE

Any regular MEDICATIONS? If so, please list the medications, their dosage and frequency, and their purpose. This information may be used to administer medications during a program, but more importantly it will help medical professionals in the event of an emergency.

CONCERNS:

NONE

Tell us any concerns you may have about participation in our programs: Any injuries or physical limitations, or any emotional, behavioral, or mental health issues, any sleep issues, substance abuse, history of infections, or anything else that you can let us know in advance to help our staff to make the program safe and enjoyable for everyone.Please note: failure to disclose significant medical or learning issues undermines our work and the safety of our programs, and we reserve the right to dismiss any participant who arrives with undisclosed conditions.

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FOR PARENTS: ARE THERE SPECIFIC LEARNING NEEDS WE SHOULD KNOW ABOUT?

Please tell us about your child's learning style, strengths and challenges, and any concerns you may have about their participation at Kroka. In addition, please disclose if your child has an IEP or any other individualized support needs.

SUBMIT THIS SECTION

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ALMOST DONE, KEEP GOING!

BACK

FOR WHOM?

HOUSEHOLD/FAMILY DETAILS:

PERSONAL INTRODUCTION

TELL US ABOUT YOURSELF:

TELL US ABOUT YOUR CHILD:

IMPORTANT DETAILS:

ALMOST DONE, KEEP GOING!