Fields marked with * are required.
Student's Home Address*
State*
Maryland Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina Norht Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Emergency Contact Information:
Person to Contact in the event of an emergency
Health Information for the Student
Please list academic, emotional/behavioral, or medical conditions of which staff should be aware:*
Date of last tetanus or DPT shot (Month/Year):
Month*
Select 1 2 3 4 5 6 7 8 9 10 11 12
Year*
Select 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
School Information
Is your student currently enrolled in a Maryland public or private school?
State
Maryland Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina Norht Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
If student is not enrolled in a Maryland public or private school, a full immunization record is required before registration is finalized. Please submit form DHMH 896 to the Kids on Campus office.
Is your student exempt from any immunization on medical or religious ground?
If student is exempt from any immunization for medical or religious grounds, please submit form DHMH 896 to the Kids on Campus office.
PARENTAL CONSENT/RESPONSIBILITIES Please check box to indicate that you have read these policies.
Attendance/Dismissal
Attendance is taken daily. Parents will be notified of absences using information submitted on consent form. For early dismissals, parents must come to HR100 and sign student out before student will be released from class. At dismissal students will be supervised until picked up or late policy comes into effect. Identification is not routinely required.
Other arrangements ( bike, walk, bus, etc.)
Parents should not leave their child on campus earlier than 10 minutes prior to the start of the class. THERE IS NO SUPERVISION FOR YOUR CHILD PRIOR TO THIS TIME; PARENTS TAKE FULL RESPONSIBILITY FOR THEIR CHILD'S BEHAVIOR AND SAFETY. Students must be picked up promptly after their classes. For 8:30AM-12PM classes, students not picked up by 12:15PM will be placed in the supervised lunchroom in the Hickory Ridge Building. For 1PM - 4:30PM classes, students not picked up by 4:45PM will be escorted to HVPA140, where they will be in supervised Wind-Down Time. THERE WILL BE A $5 LATE FEE CHARGED FOR EVERY 15 MINUTES OF LATENESS.
Medications
HCC will not administer any medications to students or allow students to self-medicate. Parents/guardians should administer any medication before or after student comes to campus. If the medication must be taken while the student is on campus, the parent/guardian is responsible for coming to campus to administer the medication. In an emergency, trained staff will administer epi pens or inhalers provided by students.
Permission to Photograph
Parental Consent Agreement
I approve of my child’s enrollment in the Kids on Campus enrichment program and take responsibility for my child's compliance with appropriate student behavior. DISRUPTIVE AND INAPPROPRIATE BEHAVIOR WILL NOT BE TOLERATED AND WILL RESULT IN DISMISSAL.
Release of Information to Howard Community College
I authorize the release of my child’s grade level to Howard Community College. This information is needed to verify either past or current enrollment in honors, gifted and talented, advanced placement, accelerated courses, or above grade level classes. This information will be submitted to the Maryland Higher Education Commission along with other enrollment data. If further information is needed, please contact Sara Baum, Continuing Education Coordinator, 410-772-4976.
Waiver of Responsibility
I/We understand and voluntarily assume all risks inherent in the nature of this activity and I/we waive and release all claims, costs, liabilities, expenses and judgements against HCC and release HCC and its representativies arising out of my child’s participation in the activity at Kids on Campus. HCC and Kids on Campus are not responsible for personal items brought or left on campus. DO NOT BRING: Games, toys, trading cards, electronic devices. All cell phones must be turned off during class hours. HCC is not responsible for lost, broken, or missing items.
Electronic Signature
THIS FORM MUST BE SIGNED AND DATED TO BE OFFICIAL IN ORDER FOR STUDENT TO BE REGISTERED. I certify the above information to be true and correct to the best of my knowledge. I understand that it is my responsibility to notify the Records Office of any change in the information contained in this application. I will take financial responsibility for my child’s tuition payment to HCC. I certify that I am registering a student for a Kids on Campus (KOC) course, that the student has resided at the above address WITH A PARENT OR LEGAL GUARDIAN for at least three months, and that the information presented here is correct to the best of my knowledge. THIS CERTIFICATION CONSTITUTES MY ELECTRONIC SIGNATURE.
