After Hour Kid Power
SUMMER CAMP 2023
Email *
Child's Name *
Email *
Address *
Phone number
Parent/Gardian
Child/ren resides with
Clear selection
Parent's/Gardian's address if different from the child's.
June 12-16
June 19-23
June 26-30
July 10-14
July 17-21
July 24-28
July 31-August 4
August 7-11
1. Emergency Contact Name, Number, and Relationship
2. Emergency Contact Name, Number, and Relationship
Family Doctor Name
Family Doctor Number
Family Hospital
Untitled Title
Untitled Title
Family Dentist Name
Family Dentist Number
Is the child taking any medication?
Clear selection
If yes, what kind?
If medication has to be administered during the program, a medication permission form must be completed.
Does your child have any of the following?
If so, please explain.
Does your child have a communicable disease or condition which may prove to be a risk to others?
Clear selection
If so, please explain.
Describe any activities from which the child should be exempted for health reasons.
In the case of an emergency, the police or paramedics may take your child to the nearest hospital for medical treatment. There may be a charge for ambulance service. Your signature authorizes program staff to use emergency services if necessary.

Parent/Guardian Signature Below
Should poison control need to be contacted, and upon their advice, we may administer syrup of Ipecac to your child to counter affect and ingestion of poison. I please sign below, here by giving Kid Power staff permission to follow this policy.

Parent/Guardian Signature Below
Policy on releases:
By signing this form, I grant permission to Kid Power to use names, pictures, and activities for the purpose of educating the public about the services available.

Parent/Guardian Signature Below
Registration Fee $50 per child or $75 per family. Payments done through Venmo @afterhourkidpower
Please list your personal Venmo information for weekly billing. (Billing maybe switched to a different service by summer.)
After Hour Kid Power Contact Info
Phone Number (651) 329-4341
Email - terrikayoum@yahoo.com
Venmo - afterhourkidpower
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