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KMA Summer Extravaganza Interest Form
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* Indicates required question
Email
*
Your email
Child's First Name
*
Your answer
Child's Last Name
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Child's Homeroom Teacher
*
Your answer
Choose your child's grade
*
1st Grade
2nd Grade
3rd Grade
4th Grade
Other:
Home Address
*
Your answer
Home Phone #
*
Your answer
Cell Phone #
*
Your answer
Email Address
*
Your answer
Choose the mode of transportation your child will need.
*
Bus
Walker
Car
Other:
Is your child currently enrolled in the KMA Afterschool Program?
*
Yes
No
Does the KMA program have permission to use photos of your child in educational or promotional materials?
*
Yes
No
Is your child under medical care or taking any medication(s)?
*
Yes
No
If you answered yes, please list all medications/allergies/ medical conditions
Your answer
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