Panola College KIDS’ COLLEGE
Panola College
Kids’ College
Registration Form
2014
Registration for KIDS’ COLLEGE will begin Saturday, April 12, 2014. Enrollment is limited and classes will be filled as
registrations are received.
_________________________________________________________________________________________________
Student Last Name
Student First Name
Grade completed
_________________________________________________________________________________________________
Parents’ or Guardians’ Names
_________________________________________________________________________________________________
Parents’/Guardians’ Home Phone
Cell Phone
Work Phone
_________________________________________________________________________________________________
Address
_________________________________________________________________________________________________
City
State
Zip Code
_________________________________________________________________________________________________
E-Mail Address
Tuition Payment
KIDS’ COLLEGE T-Shirts
Early Registration (before April 18):
Please circle the appropriate size.
Number of kids _____ X $130.00
Regular Registration (after April 18):
Number of kids _____ X $150.00
Siblings (added to first full-price enrollment):
Number of kids _____ X $130.00
Child Sizes
Adult Sizes
Small
Small
Medium
Medium
Large
Large
Extra Large
Deadline to register is May 16 at 12:00pm, or
until classes are filled
XX Large
There will be no refunds after May 23, 2014.
Payment Information:
Total Amount Paid: $___________________________________ Date:_____________________________
Form of Payment: Cash
Check
Check #___________Visa
MC
Discover
AE
Credit Card #:______________________________________ Exp. Date:____________________
Name as it appears on Card:_________________________________________________________
Signature: _____________________________________________________________________________
Panola College is an equal opportunity institution that provides educational and employment opportunities on the basis of merit and without
discrimination because of race, color, religion, sex, age, national origin, veteran status, disability or genetic information.
Panola College
Kids’ College
Permission, Medical, & Media Release Form
2014
_____________________________________ has my permission to participate in Kids’ College 2014 sponsored by Panola College.
Allergies (food), medications, dietary restrictions, health problems or any other special considerations we need to be aware of:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Medical Release
Parent/Guardian Signature: ________________________________
Preferred Physician: ______________________________________
Dr. Phone: _____________________________________________
Preferred Hospital: _______________________________________
Emergency Contact: ______________________________________
Phone: _________________________________________________
Insurance Carrier: ____________________________________________
Policy #: _____________________________________________________
In the ev ent of a m ed i cal em e rg e n cy , I autho ri ze
the pe r sonnel o f P an o la Co ll eg e K id s’ Co lleg e to
seek app rop r iate m ed i ca l atten t io n fo r m y chil d.
The following people have permission to pick up my son/daughter:
Name: ________________________________________________
Phone: ________________________________________________
Name: ________________________________________________
Phone: ________________________________________________
Name: ________________________________________________
Phone: ________________________________________________
MEDIA RELEASE
I hereby authorize Panola College to photograph my child/children
and any subject matter owned by me or my child, in still picture and
motion picture form, and to record my child’s voice, or to cause
such photographs and pictures and recording to be made. I
hereby consent to the exhibition of such photographs and pictures
and the use of my child’s name and voice by you, the world,
whether such exhibition and use are sponsored or not. I also
consent to the use of such photographs, the right to use my child’s
name, voice and photographs and pictures in advertising and in
publicity in connection with a subsequent exhibition, and in the
exhibition itself.
I hereby release you and all other parties from any and all liability,
. claims or causes of action, arising out of, or created by, the use of
my child’s photograph or photographs, picture or pictures, and
name and voice, as set forth above.
This authorization, consent and release shall apply to all
photographs, pictures and recordings of the above-signed, made
with the knowledge and acquiescence of the above-signed, from
the date hereof until the above-signed shall give you written notice
that this authorization, consent and release in no longer effective.
This agreement shall be binding on me, my heirs, administrators
and executors, and shall inure to the benefit of you, your
successors, assigns or licensees.
Participant Name: ______________________________________
Parent/Guardian Name (Print): ____________________________
Parent/Guardian Name Signature: _________________________
RELEASE & WAIVER OF LIABILITY
The undersigned hereby acknowledges that participation in this camp and related activities involves a possible risk of physical injury.
The undersigned on behalf of the registrant, hereby assumes all such risk and does hereby release and forever discharge the camp
and all the employees and agents thereof from any and all liability of whatever kind or nature, rising from and by reason of any and all
known and unknown, foreseen and unforeseen, bodily injury and personal injuries, damage to property, and the consequences thereof,
resulting from the registrants participation in or involvement with this camp, including any failure of equipment or defect in the premises.
I hereby state that I am the legal guardian of said registrant.
Participant Name: _______________________________ Parent/Guardian Name (Print): __________________________________
Date: _____________________
Parent/Guardian Name (Signature): _____________________________________________
Parent/Guardian Signature: _________________________________ ________ Date: ______________________
Panola College is an equal opportunity institution that provides educational and employment opportunities on the basis of merit and without
discrimination because of race, color, religion, sex, age, national origin, veteran status, disability or genetic information.
Schedule of Classes
CHOOSE YOUR ADVENTURE!
Check out the Class Blocks below. Choose your favorite block (you will attend the classes listed in the block). Put a 1 on the line
above the block for your first choice and a 2 for your second choice, just in case the block you have chosen is full. Descriptions of
the courses listed are included on the next page of the registration packet.
__________
__________
World Tour: Countries and Cultures
Fantasy World: Anything Goes
7:45
Arrival/Warm-Up
7:45
Arrival/Warm-Up
8:00
World of Arts
8:00
Out-of-This-World Movement and Motor Lab
9:30
Global Games
9:30
Create-a-Character: Aliens and Superheroes
11:00
Texans Workshop/Stay Safe/Lunch
11:00
Lunch/Stay Safe/Texans Workshop
12:30
Discover Earth
12:30
Freaky Fitness
2:00
Out-of-This-World Movement and Motor Lab
2:00
Unnatural Science
3:15
Cool Down/Pick-Up
3:15
Cool Down/Pick-Up
__________
__________
Going Global: Fun and Fitness
Real World: Build Your Own Awesome
7:45
Arrival/Warm-Up
7:45
Arrival/Warm-Up
8:00
Design Challenge
8:00
Sports Classics
9:30
Out-of-This-World Movement and Motor Lab
9:30
Spherical Science
11:00
Stay Safe/Lunch/Texans Workshop
11:00
Texans Workshop/Lunch/Stay Safe
12:30
Construction Arts
12:30
Out-of-This-World Movement and Motor Lab
2:00
Obstacle Course/Circuit Training Construction
2:00
Global Art
3:15
Cool Down/Pick-Up
3:15
Cool Down/Pick-Up
Panola College is an equal opportunity institution that provides educational and employment opportunities on the basis of merit and without
discrimination because of race, color, religion, sex, age, national origin, veteran status, disability or genetic information.