Graffiti Kids Summer Program

If your child has an IEP, 504 Plan, or has special needs, please apply in person to determine eligibility.

No refunds are provided once a student is enrolled as we have very limited program space. Please be sure our program fits your schedule before you submit your payment. We invite you to meet with our staff in person if you have any questions or concerns.

Download Application to print and submit in person instead of using the online form.

Child's Name

Date of Birth

Gender

Male
Female

Grade Just Completed

Child's School

T-Shirt Size

Does this child have any prescribed medications

Does this child have any allergies

If your child or his/her sibling attended the Graffiti Kids After School for the 2016-2017 school year, Hip Hop, or the Graffiti Kids Summer Program in 2016, then you are eligible for a reduced rate for our summer program and can select "returning child."

Please Select Your Registration

I certify the child listed above does not require an IEP, 504 Plan, and does not have special needs or require special care.*

Parent / Guardian Information

Parent/Guardian Name

Phone Number

Address

Emergency Contact Name

Emergency Contact Phone

Does Your Family Attend Church?

We allow up to 6 adults (over 18 years old) to be listed as authorized to pick up your child/children from our Summer Program. Please indicate below if you need to add persons, and continue to do so for up to 6 people.

Add Adult #1

Cancellation and Policy Agreement

We are excited your child will be joining us for the Graffiti Kids Summer Program. Guardians will need to fill out our Release of Liability form. The form can be obtained in person at Graffiti, can be printed and brought with your child on the first day of program, or emailed to [email protected]. We have also included our Cancellation Policy and Online Agreement Consent. If you have any questions or concerns, please contact us before finishing your application.

I understand if I am late picking up my child / children from the Graffiti Kids Summer Program, I am required to pay an additional $5.00 cash for every 5 minutes after 4:00pm for each child enrolled. The additional payment must be paid within 3 program days of the late pickup date in order for my child to continue attending program.*

I understand payment does not guarantee placement in summer program. My child's position is held until the form required for attendance - Release of Liability, Medical Consent, Travel Permission, and Photo Release are submitted. This form can be obtained in person, downloaded, or emailed upon request and can only be signed by a legal parent/guardian.*

I understand that acceptable behavior is a condition of my child's enrollment in the Graffiti Kids Summer Program. I understand my child must follow the rules, policies, and procedures outlined in the Parent Orientation Packet which will be given on the first day of program. Unacceptable behavior will be corrected verbally, with time-outs, meetings with parent/guardians, and lastly suspension/expulsion with no refund eligibility.*

Terms and Agreement

I have read and agreed to the terms above and I understand there are no refunds after submitting payment for Graffiti Kids Summer Program. By signing this form I acknowledge that the policies above apply to every child I enroll.

I, the undersigned, agree to the terms above.

Total

$0.00

Billing Information

Name

Credit Card

Visa
Mastercard
Discover

Address

Confirm Email

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