KROKA EXPEDITIONS

Pirates of Lake Champlain

Sun Jul 2 - Sat Jul 8, 2023 (7 days)

AGES: 11 - 13

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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YOU MUST CHOOSE ONE OF THESE OPTIONS:

$1,950.00

TUITION SUMMER ONE-WEEK, Level A
Household Annual Income of $185,000 or more

$1,650.00

TUITION SUMMER ONE-WEEK, Level B
Household Annual Income of $100,000 - $185,000

$1,450.00

TUITION SUMMER ONE-WEEK, Level C
Household Annual Income of $70,000 - $99,000

$1,150.00

TUITION SUMMER ONE-WEEK, Level D
Household Annual Income of $50,000 - $69,000

$850.00

TUITION SUMMER ONE-WEEK, Level E
Household Annual Income of $30,000 - $49,000

$700.00

TUITION SUMMER ONE-WEEK, Level F
Household Annual Income up to $29,000

CLICK TO CHOOSE ANY OF THESE OPTIONS:

FEEEQUIPMENT-RENTAL, RAIN-COAT, Weekly

$20.00

FEEEQUIPMENT-RENTAL, RAIN-PANTS, Weekly

$20.00

FEEEQUIPMENT-RENTAL, RUBBER-BOOT, Weekly

$5.00

FEEEQUIPMENT-RENTAL, SLEEPING-BAG, Weekly

$25.00

FEEEQUIPMENT-RENTAL, SLEEPING-PAD, Weekly

$5.00

FEEEQUIPMENT-RENTAL, WATER-SHOES, Weekly

$5.00

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PARENT AGREEMENT FOR SUMMER REGISTRATION

YOU'RE ALMOST DONE WITH THE REGISTRATION FORM... BUT BEFORE YOU GO ANY FURTHER:

We need to make sure you understand our admissions policies. Because of the unique and challenging nature of our summer programs, we take extra care in the registration process and may not admit every child. Before accepting any student, we strive to ensure that:

The student has genuine interest in the program and is excited to come
The student is physically fit enough to participate in all aspects of the program
The family shares a mutual understanding of our unique philosophy and approach to programming

Once you complete the registration process, someone from our office may give you a call to get to know you further and help ensure Kroka will be a good fit for your family. Before you complete this form, please confirm that:

1) You have read and understand our Parent/Student Handbook (this has been developed over the years to try to give you a complete picture of what to expect while at Kroka and how to prepare for the experience

2) The student is personally excited to come to Kroka and is choosing this experience

We look forward to seeing you next summer!

I have read and understand the above and I am ready to move forward with the registration process / YES | NO

YES

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!

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