2009 Nickelodon Parents Picks Award

Schools Out Camp

Name

Gender

Age/DOB

Work Phone

Cell Phone

Parent or Guardian Name:

Address
Email
Home Phone

Other responsible escorts/emergency contacts?

Name

Phone

Name

Phone

Camp Days 2015-16: 9/14, 9/15, 9/23, 9/24, 10/12, 11/3, 11/11, 12/23, 12/29, 12/29, 12/30, 1/18, 2/15,
2/26, 3/18, 3/21, 3/22, 3/23, 3/24, 3/25, 4/26, 4/1, 4/26
KO12th Closed: 9/25, 11/27, 11/28, 12/24, 12/25, 12/26, 12/31, 1/1, , 5/25
Select your schedule, please indicate day and dates below:

Single day camp, members pay $35

Single day camp, drop ins pay $60 until
4:00, $5 per hour aftercare
Payment due

Winter or spring break, members price $45

Winter or spring break, non-members $60
until 4:00, $5 per hour aftercare

Camp hours from 8:30am until 4:00pm with aftercare available until 6:15 for an additional $5 per hour.
Credit card payment authorization: Upon completion of credit card information, I authorize Philadelphia Kids Club/Kids On 12th to charge the amount
indicated to the card listed. The card number will not be kept on file.

Visa

Mastercard

Name on Card

Discove
r

Exp. Date

V-code
Card #

Philadelphia Kids Club is an Equal Opportunity Provider, we welcome all friends! Responsible Party Waiver Adult escorts may be asked for
identification at anytime by Philadelphia Kids Club staff and verification may be made by phone contact with parent or Emergency Contact.Personal
General Waiver I understand that my child will engage in physical activity in the KOI2 facility and areas of 12th Street Gym available to KOI2 members
as well as walking trips in the care of KO12 staff to outdoor play areas. I accept that there may be risk of injury during that activity. I accept all conditions
of the risk of illness, injury and loss to myself or my child and/or personal property or theft of such property. A separate medical form is required for all

A division of Philadelphia Kids Club

201 South Camac Street :: Philadelphia, PA 19107 :: www.kidson12th.com

2009 Nickelodon Parents Picks Award

kids registered.

Parent or Guardian Signature______________________________________________________

Date _____________________________

A division of Philadelphia Kids Club

201 South Camac Street :: Philadelphia, PA 19107 :: www.kidson12th.com