Parent's Name *

First Name

Last Name

Parent's Phone Number *

(###)

###

####

Home Mailing Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Child's Name *

First Name

Last Name

Child's Birthdate *

MM

DD

YYYY

IEP - Individualized Education Program *

Yes, my child has an IEP.

No, my child does NOT have an IEP.

Permission to participate in ride sharing services *

Yes, I consent to allowing my child to utilize the ride sharing services arranged by Kismet of Kings facilitators.

No, I do not consent to allowing my child to utilize ride sharing services.

Release of Information *

By selecting this option and completing my submission, I hereby grant permission for my student to participate in the Kismet of Kings after-school program conducted by Kismet of Kings After School Program. I understand that this program involves various activities and may include outings, events, and workshops both on and off-campus. I authorize Kismet of Kings, its staff, volunteers, and affiliates, to collect and use information related to my son's participation in the program for the following purposes: 1. Program coordination and planning. 2. Communication with me regarding my son's involvement and progress. 3. Promotional materials, including photographs and videos, for the purpose of promoting the program. I understand that the information collected may include, but is not limited to, my student's name, age, contact information, academic performance, and any other relevant details pertaining to his participation in the program. I acknowledge that Kismet of Kings will take all reasonable precautions to ensure the confidentiality and security of the information collected. However, I release Kismet of Kings and its staff from any liability arising from the use or disclosure of information as described in this form. I understand that this release of information will remain in effect for the duration of my son's participation in the Kismet of Kings after-school program, unless revoked by me in writing.

I understand and agree to the terms of this Release of Information