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Returning Childfull name
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Payments are due 2 weeks in advance.
WE ARE FULL FOR RISING 1ST, 2ND and 3RD GRADERS AS OF 5/26/22
My Child Will AttendChoose Dates

Has my permission to attend/travel to the following field trips during Kid Central Summer Day Camp,
May 30-August 3, 2017


  • DOMINION SKATING CENTER, CULPEPER (all) 
  • REMINGTON SWIM CLUB, REMINGTON (all) 
  • VIRGINIA SAFARI PARK (Grades 3-6) 
  • RIVERSIDE DINNER THEATER, FREDERICKSBURG (girls only) 
  • SPLASHDOWN WATER PARK, MANASSASS (Grades 3-6) 
  • CHUCK-E-CHEESE, MANASSASS (Grades K-2) 
  • SOCA KNOCKERBALL (boys only) 
  • NATIONAL HARBOR WITH A RIVERBOAT TAXI RIDE from ALEXANDRIA VA (Grades 3-6) 
  • BOUNCE AND PLAY, CHARLOTTESVILLE (Grades K-2) 
  • SKATE N FUN ZONE, MANASSAS (all) 
  • RICHMOND ZOO (Grades K-2) 
  • SHERONDO PARK, STEPHENS CITY, VA (all) 
  • MASSANUTTEN WATER PARK, McGAHEYSVILLE (Grades 3-6) 
  • DISCOVERY MUSEUM, CHARLOTTESVILLE (Grades K-2) 
  • A DREAM COME TRUE PLAYGROUND, HARRISONBURG (all) 
  • SKYZONE, MANASSAS (Grades 3-6) 
  • KINGS DOMINION (all) 
Swimming Permission Form

My child has my permission to go swimming at THE CULPEPER REC CLUB in CULPEPER, VA with KID CENTRAL Summer Camp Staff.

Sunblock Permission 

When I supply Kid Central Staff with Sunscreen: 

  • I give them permission to apply it to my child(ren) ages 5-8 years of age 
  • Remind my child(ren) ages 9-12 years to apply it to themselves.
Will My Child Swimcheck one
My Child is acheck one

Kid Central - Returning Child Registration (your child must have been enrolled in Kid Central within the last school year to use this form)
1. Emergency and Identification Information
Child's Namelast name first
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Birth Date
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Child's Home Address
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School
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Rising Grade
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Mother's Name
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Mother's Cell Phone
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Mother's Home Phone
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Mother's Home AddressIf different from child
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Mother's Business Address
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Mother's Work Phone
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Father's Name
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Father's Cell Phone
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Father's Home Phone
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Father's Home AddressIf different from child
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Father's Business Address
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Father's Work Phone
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Desired Start Date
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2. Name of persons authorized to take the child from the facility. (The child will not be allowed to leave with ANY other person without written authorization from parent or guardian).
Namefull name
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Phone
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Relationship to Child
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Address
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Namefull name
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Phone
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Relationship to Child
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Address
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Additional Pick Ups
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PICK UP RESTRICTIONSCANNOT PICKUP
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3. Allergies and/or Medical Limitations
Please explain any allergies or medical limitations (if not applicable put N/A):If your child needs medication administered by us; we MUST have a Medical Authorization form with the correctly labeled meds included. The MAT form must be completed by the parent and the doctor. If your child has a Food Allergy, we must also have an Allergy and Anaphylaxis Action Plan.
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We often take photos and post them to social media, newspapers, etc. Do you agree that your child may be photographed.
This institution participates in the Child and Adult Care Food Program (CACFP) and receives Federal reimbursement to provide nutritious meals for children. Federal CACFPregulations require all parents/guardians to complete and sign a separate Annual Enrollment Form for each child when enrolling their child(ren) with this provider, and every 12 months thereafter. By registering for Kid Central I understand I am enrolling in the CACFP. My Child will be attending M-F between the hours of 6:30 am -6:30 pm receiving Breakfast, AM Snacks, Lunch and or PM Snacks as appropriate. This institution is an equal opportunity employer.
I agree that all other information provided on the 20-21 school year registration is still accurate.

Signatureyour full name
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Date
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