2022 Registration Form

Student Information
First Name *
Legal First Name
Last Name *
Legal Last Name
Gender *

Male Female
Birth Date *

Month Day Year
Home Phone *

Area Code Phone Number
Has your child participated in previous KAP afterschool or summer programs? *
is there a particular workshop that you are signing your youth up for? If so, please enter the name of that workshop here.
Does your child have any special needs or behavior concerns that require extra care and attention? If so, please explain in detail.
Please tell us about your child. Describe his or her interests, hobbies, extracurricular activities, and anything else that will help us get to know your child better. *

Youth School Information
Grade *
What gade will your youth be enrolled in for the 22-23 School Year?
School *
What is the name of the school that your youth will attend in the 22-23 school year?
Parent/Guardian Information 1
Full Name *

First Name Last Name
Home *

Area Code Phone Number
Cell *

Area Code Phone Number
Work

Area Code Phone Number
E-mail *

Emergency Contact

Other than Parent/Guardian
Full Name *

First Name Last Name
Home *

Area Code Phone Number
Work

Area Code Phone Number
Cell *

Area Code Phone Number
Medical
Does your child have any allergies? If yes please list, including any food or drug allergies.

Permissions
Survey Requirement *

I authorize Ketchikan Afterschool Program to survey my child occasionally solely for the purpose of improving the program. I understand that I will be notified of surveys in advance and will be allowed to view the survey questions upon request before-hand.
Photo Release: I give permission for KAP to take and use photos which may include my child for the purpose of promoting the program (e.g. on our website, in program brochures). *

Would you be interested in volunteering, chaperoning, or leading a youth project?

Yes Maybe No
This program is primarily funded through sales tax from marijuana dispensaries. As part of the grant, the state of Alaska requires us to conduct a marijuana education curriculum for youth/student attendees. Please indicate below if you would be willing to let your student attend 6-12, 30-60 minute afterschool lessons on the laws and health concerns regarding underage marijuana usage.
Healthy Lifestyles Opt-Out *

I authorize my child to participate in 6-12 Healthy Lifestyles lessons about laws, health effects and safety regarding illegal youth marijuana usage and making healthy choices. I do not authorize my child to participate in 6-12 Healthy Lifestyles lessons about laws, health effects and safety regarding illegal youth marijuana usage and making healthy choices.

Paper Version
I request the program van to drop off my youth in the evenings (activities end at 5:30) due to the follow:

Lack of Access to a Vehicle at Home Parent/Guardian Works in the Evening
Signature

Clear
Please scroll down to complete this form
Bouldering Waiver

Please read and sing below to give your child permission to use our bouldering wall. This is optional.
Climber's Name

First Name Last Name
Signature of Parent/Legal Gardian for Bouldering waiver

Clear

KAP-Ketchikan Afterschool Program