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K i d College
Kids’
NEW THIS
YEAR:
Order a camp
T-shirt (optional)
2016
REGISTRATION FORM
Please use a separate form for each child. Complete both sides of the registration form and mail to:
Stark State College, Education Department, 6200 Frank Ave. NW, North Canton, Ohio 44720
Child’s name ___________________________________________________ Social Security number (for office use only)_____________________________
Address _________________________________________________________ City/State/Zip _________________________________________________
Date of birth _________________________________________ Parent/guardian name _______________________________________________________
Home phone ______________________________________________________ Work phone __________________________________________________
Cell phone ___________________________________________ Parent’s email ___________________________________________________________
School _____________________________________________________________________________ Grade (as of spring 2016) ____________________
List all authorized persons for student pick up, INCLUDING parents/guardians (photo ID must be presented at time of pick up) ____________________________
___________________________________________________________________________________________________________________
Does your child have a medical or learning need we should know about, i.e. allergy, medication, disability? ____ No ____ Yes, please describe:
___________________________________________________________________________________________________________________
Payment must accompany registration. Make checks payable to Stark State College.
Select payment: m Check enclosed (total amount) $ ________________
m Debit card
mVisa
m MasterCard
m Discover
Debit/credit card number ___________________________________________________ Exp. date _______________________
Total amount $________________________ Name on credit card _______________________________________________________________________
Card billing address ___________________________________________________________________________________________________________
Select week(s) desired
Week 1 June 6-9
____ Morning only ($69)
____ Afternoon only ($69)
____ All day ($109)
Week 2 June 13-16
____ Morning only ($69)
____ Afternoon only ($69)
____ All day ($109)
Week 3 June 20-23
____ Morning only ($69)
____ Afternoon only ($69)
____ All day ($109)
Week 4 June 27-30
____ Morning only ($69)
____ Afternoon only ($69)
____ All day ($109)
$ _________________
Registration fees
$ _________________
Materials fees
$30 per week for all day
registration
$20 per week for morning
or afternoon only registration
$ 5 T-Shirt (optional)
Select size below, if interested.
m Yes, I would like to order a
Kids’ College T-shirt for an
additional $5
Size: m Youth S m Youth M m Youth L m Youth XL
m Adult S m Adult M
$ _________________
Total due
Cardholder signature (required for debit/credit card payment) _____________________________________________________________________________
The undersigned, as parent or guardian of the child named above, desires that my child participate in Kids’ College. By execution of this release form, I agree that all requirements, directions and standards set by staff, use of any equipment or supplies under the supervision of the staff, shall be deemed to
have been accomplished for the benefit of my child. I also grant permission that any pictures taken containing my child may be used for future promotional purposes. In the consideration of Stark State College’s efforts on my child’s behalf, I do hereby voluntarily assume all risk of accident, injury,
damage and/or loss to my child’s property that may arise out of child’s participation in Kids’ College, hereby intending to release and discharge Stark State College, its Board of Trustees, officers, employees and agents associated or connected with Kids’ College from every claim, liability or damage of any
kind caused by negligence of Stark State College, its Board of Trustees, officers, employees or agents involved or otherwise that may result from my child’s participation in Kids’ College. The undersigned acknowledges that the child named is a minor under the age of 18. Although a minor, my child is aware
of the risks involved with participating in Kids’ College. I assure Stark State College that I have carefully counseled my child on the risk of participating. Further, I assure Stark State College that there are no physical or other reasons that preclude my child from participating in Kids’ College. I authorize Stark
State College to obtain such medical care, emergency or otherwise, that it may in its sole discretion deem necessary for my child. Further, I assure Stark State College that I have adequate health insurance or personal funds to provide payment for all costs of medical care necessary for my child. I agree to
indemnify and hold harmless Stark State College for any costs associated with such care.
__________________________________________________________________________________________________________________________
Parent or Guardian Signature
Date
*HIGHLIGHT INDICATES COURSE IS FULL*
REGISTRATION FORM
WEEK 1 June 6-9
10:25 - 11:25 a.m.
1:00 - 2:30 p.m.
2:35 - 4:05 p.m.
AFTERNOON
11:30 a.m. - 12:30 p.m.
MORNING
9:20 - 10:20 a.m.
GRADES 1-3
GRADES 4-7
• Indicate your first and second choice by putting (1) and (2) for your class preference in each time block.
• SIGN UP FOR THE GRADE LEVEL AS OF SPRING 2016. Please use a SEPARATE FORM for each child
WEEK 2 June 13-16
GRADES 1-3
GRADES 4-7
WEEK 3 June 20-23
GRADES 1-3
GRADES 4-7
WEEK 4 June 27-30
GRADES 1-3
GRADES 4-7
__Camp Out on Campus
__Measurable Munchies
__Broadway Bound
__Kids in the Kitchen
__Famous Artwork
__Snakes, Birds and
Butterflies-Oh My!
__Journaling Fun
__Brain Quest Challenge
__Recycled Prints
__Animal Sculpture
__Crime Scene Investigators
__Balloon Man I
__Fossil Frenzy
__Exploring STEM
__What’s the Matter?
__Be an Author
__Bubble-ology
__Farming 101
__Moving and Groving
Dance
__What’s a Polymer?
__Legomania
__Camp Out on Campus
__Design a Theme Park
Attraction
__Cute Crafts for Girls
__Ballroom Dancing
__Beyond Go Fish and War
__Orient Express-ions
__Our Solar System
__Camp Out on Campus
__Measurable Munchies
__Yucky Science
__If You Give a Mouse a
Cookie…
__Disney Crafts
__Colonial America
__Our Solar System
__Brain Quest Challenge
__Movie Maker
__Wacky Weaving
__Crime Scene Investigators
__Balloon Man II
__Biology is Life!
__Healthy Kids
__Animal Sculpture
__Kids in the Kitchen
__Frozen Fun
__Moving and Groving
Dance
__Balloon Man I
__Karaoke Kids
__Magic! Magic! Magic!
__Minecraft Masters
__Camp Out on Campus
__Movie Maker
__Backyard Olympics
__Design a Theme Park
Attraction
__Science is Not a
Spectator Sport
__My Favorite Book
__Sweet Science
__Recycled Prints
__Animal Sculpture
__Crime Scene Investigators
__Balloon Man I
__It’s Raining, It’s Pouring
__Karaoke Kids
__Brain Quest Challenge
__Camp Out on Campus
__Stupendous Stumpers
__Kids in the Kitchen
__Art Class Fun
__Colonial America
__Exploring STEM
__Camp Out on Campus
__Happily Ever After
__Bubble-ology
__Farming 101
__Famous Artwork
__All About Eric Carle
__Legomania
__Be an Author
__Design a Theme Park
Attraction
__Cute Crafts for Girls
__Backyard Olympics
__Science is Not a
Spectator Sport
__Game-o-Rama
__Creepy Critters
__Sweet Science
__Wacky Weaving
__Crime Scene Investigators
__Christmas Around the
World
__Making Music with
Recorders
__Expedition Egypt
__Creepy Critters
__ Brain Quest Challenge
__ Camp Out on Campus
__ Movie Maker
__ Yucky Science
__ Balloon Man II
__ Magic or Science?
__ Settlers of Catan
__Camp Out on Campus
__Duct Tape Designs
__Frozen Fun
__All About Eric Carle
__It’s Raining, It’s Pouring
__Balloon Man II
__My Favorite Book
__Minecraft Masters
__Movie Maker
__Kids in the Kitchen
__Baseball Fundamentals
__Colonial America
__Geometry Construction
__Karaoke Kids
__Reading Club/Readers
Theatre
__Animal Adaptations
__Spa Science
__Duct Tape Designs
__Survivor Island
__Expedition Egypt
__Fun with Fibers
__Mind Blossom
__Balloon Man I
__Kids in the Kitchen
__Ballroom Dancing
__Karaoke Kids
__Magic or Science?
__Geometry Construction
__Mind Blossom
__Broadway Bound
__Survivor Island
__Disney Crafts
__Symphony of 5 Senses
__Orient Express-ions
__Girls’ World
__ Fractured Fairytales
__ Shibori Tie Dye
__ Stage Performance/
Comedy
__ Friendship Bracelets
__ Project: Probability!
__ Chemistry of Cooking
__ Games Galore
__Reading Club/Readers
Theatre
__Wacky Weaving
__Coloring Fun
__Balloon Man II
__What is a Polymer?
__Basketball Fundamentals
__Games Galore
__ Mind Blossom
__ Movie Maker
__ Poetry Pizzazz
__ Stampin Mania
__ Game-o-Rama
__ Counting Cards
__ Puppets and
Ventriloquism
__Minecraft Masters
__Mind Blossom
__Kids in the Kitchen
__Foam Art
__Colonial America
__Snakes, Birds and
Butterflies-Oh My!
__Our Solar System
__ Movie Maker
__ Duct Tape Designs
__ Cross Stitch and Sewing
__ Words are Power
__ Counting Cards
__ Balloon Man II
__ History of Fun Food
__Reading Club/Readers
Theatre
__Art Class Fun
__Fantastic Fossils
__Softball Basics
__Magnet Mania
__Christmas Crafts
__Teamwork
__4 Square
__Spa Science
__Fun with Fibers
__Science of Movies
__Sign Language
__Stage Performance/
Comedy
__Hollywood Special
Effects/Make-Up 1
__4 Square
__Little House Living
__Stage Performance/
Comedy
__Christmas Crafts
__Fairy Tale Readers
Theatre
__Painted Pet Rocks
__World Tour
__Polymer Clay Creations
__Survivor Island
__Fantasy Baseball
__Colorful Calculations
__Can You Build a Bouncer?
__Periodic Table Madness
__Hollywood Special
Effects/Make-up 2
__Reading Club/Readers
Theatre
__Stampin Mania
__Perler® Bead Creations
__Sign Language II
__Abstract Art
__Legomania
__Teamwork
__4 Square
__Digital Camera Capers
__Design a Theme Park
Attraction
__Cooking with Math
__Can You Build a Bouncer?
__Hollywood Special
Effects/Make-up 3
__Druidawn
__ 4 Square
__ Patriotic Spirit
__ Our Solar System
__ Big Hats & Wigs
__ World Tour
__ Coloring Fun
__ Sign Language (mixed)
__Digital Camera Capers
__Shibori Tie Dye
__Colorful Calculations
__Beyond Go Fish and War
__Comics and Cartoons
__Hollywood Special
Effects/Make-up 3
__Druidawn
__Pets and People
__4 Square
__Fantastic Fossils
__Sign Language
__Blocks of Fun
__Disney Crafts
__Hollywood Special
Effects/Make-Up 1
__Let’s Make Books
__Broadway Bound
__Survivor Island
__Friendship Bracelets
__Yoga
__Animals Inside and Out I
__Druidawn
__Vintage Toys for Modern
Day Kids
__Polymer Clay Creations
__Softball Basics
__Jungle Safari
__Fun Suncatchers
__Basketball Fundamentals
__Hollywood Special
Effects/Make-up 2
__4 Square
__Broadway Bound
__Yoga
__Cross Stitch and Sewing
__Fantasy Baseball
__Colorful Calculations
__Animals Inside and Out II
__ Pets and People
__ 4 Square
__ Design a Theme Park
Attraction
__ Druidawn
__ Comics and Cartoons
__ Let’s Have a Party
__ Puppets and
Ventriloquism
__ Let’s Make Books
__ Digital Camera Capers
__ Scrapbooking and
Memory Pages
__ Perler® Bead Creations
__ Cooking with Math
__ Animals Inside and Out I
__ Sign Language II
__Magic! Magic! Magic!
__Shibori Tie Dye
__Animals Galore
__Perler® Bead Creations
__Pop-Up, Fold-it and
Stick-it
__History of Fun Food
__Druidawn
__ 4 Square
__ Digital Camera Capers
__ Sign Language (mixed)
__ Monopoly Masters
__ Coloring Calculations
__ Abstract Art
__ Animals Inside and Out II