2017 Kids' College COM
Pre-Admission Form


Kids' College Home


Please complete ALL fields.
Students will not be enrolled without their own social security number.
Social Security Number:    
Last Name: First Name:
Middle Initial:    
Street Address: City:
State: Zip Code:
Home Phone:    
Date of Birth: (m/d/y) Age:
Sex: *Grade completing now (must be in grade 7-9 in 2016/2017 school year)
   



Ethnicity:  
White Non-Hispanic Black Non-Hispanic
Hispanic Asian or Pacific Islander
American Indian or Alaskan Native Other
I decline to give Ethnicity  
   
Have you attended Kids' College before?

  If Yes, When?
Email Address:
You must supply a valid email address. A message will be sent to this address confirming your form submission.


Parent/Guardian  
Name
Day phone
Cell phone/pager
Email
Parent/Guardian  
Name
Day phone
Cell phone/pager
Email


Emergency Release Form

If I cannot be reached to make plans for emergency medical care for my child at the time of an illness or accident,

I, give permission for Midland College staff
to take my child,*

to:
and
(Name of doctor)
 
(Name of hospital)
 
(Phone number of doctor)
 
(Phone number of hospital)

Student’s known allergies or significant medical history:


I/We do hereby release, absolve, and hold Midland College harmless with respect to liability in case of injury to my/our child while participating in Kids’ College activities.

Midland College takes photographs of Kids’ College activities for use in its publications, advertising and website to promote the Kids’ College program and Midland College in general. If you do not want your child’s pictures to be included in any of these promotional pictures, please designate as such.

OK to include child in pictures
Please do NOT include my child in pictures

Refund policy: Class fees will be refunded only if a student withdraws by noon on the Thursday preceding the first day of the session or if Kids’ College must cancel a course.

Parent/Guardian, Please check the box to the left indicating that you have read the statements above and agree to the information you are submitting.