VIRGINIA COMMUNITY COLLEGE SYSTEM
NONCREDIT APPLICATION FOR REGISTRATION
Paul D. Camp Community College
KIDS COLLEGE – SUMMER 2016
For Admin Use Only
EMPL ID
STUDENT INFORMATION
1. Have you ever taken a Kids College course before? ____ Yes ____ No
2. Child’s Name:
__________________________________
Full First
Full Middle
Full Last
Suffix (Jr., Sr., II, III, other)
3. * Parent’s Email: __________________________________________________________________________________________________
4. Date of Birth: _____ / _____ / _____
Month
Day
5. Age (as of 6/20/16): ________
6. Grade (as of 9/1/16): __________
Year
School: ____________________________
7. Parent/Guardian’s Name: _________________________________________________________________________________________
8. Best Phone: (_____) ______ - _______
Additional Phone: (_____) ______ - _______
9. Mailing Address:
_____
Street
Apt. /Suite
City
State
Zip
10. How did you hear about Kids College 2016? ________________________________________________________________________________
ETHNICITY/CITIZENSHIP
11. Are you Hispanic or Latino: ____ Yes ____ No
12. Gender: ____ Male ____ Female
13. Racial/Ethnic Group: ____ American Indian/Alaska Native
____ Native Hawaiian/Other Pacific Islander
14. What is your citizenship status? ____ Native (U.S. citizen at birth)
____ Alien Permanent
____ Asian
____ Black/African American
____ White
____Naturalized (became U.S. citizen after birth)
____ Alien temporary
____Not living in the U.S.
15. Primary Language ____ English _____ Other
I certify that all of the above information is complete and accurate. I agree to supply the college with supporting
documentation related to my application, if I am requested to do so.
Parent's Signature: ______________________________________________________ Date:
PHOTOGRAPHY RELEASE
I give permission to Paul D. Camp Community College to use photographs of my child for college publications or
advertisements in print or electronic media. I consent to the use of his/her name, likeness, voice, and biographical
material about him/her in connection with college publicity or institutional purposes.
Parent’s Signature: ______________________________________________________ Date: _______________________
This institution promotes and maintains educational opportunities without regard to race, color, sex, ethnicity, religion, gender, age
(except when age is a bona fide occupational qualification) handicap, national origin or other non-merit factors.
Kids College
Division of Workforce Development, Paul D. Camp Community College
100 N. College Drive, Franklin, VA 23851
Phone: 757.569.6700 Fax: 757.569.6055
kidscollege@pdc.edu
Revised 4/28/2016
For Admin Use Only
KIDS COLLEGE 2016 REGISTRATION
EMPL ID
Student Name: ___________________________________
Course Name
Grade child will enter this fall: _____
Times
Date
METHOD OF PAYMENT
Please circle:
Location
(Franklin,
Smithfield,
Suffolk, Windsor)
Cost
Subtotal
Cash
Check
Credit Card
WE WELCOME AND ENCOURAGE CREDIT CARD PAYMENTS!
Refunds on payments made by check or cash will require you to provide your
social security number to receive those refunds and may take several weeks to
process. Refunds on payments made by credit card will NOT require providing
your social security number and will be directly refunded to your credit card.
Credit card numbers are not kept on file for your security.
HOW TO REGISTER
Email your scanned forms at kidscollege@pdc.edu
DO NOT INCLUDE CREDIT CARD INFO!
Call 757.569.6058 to make a payment.
Fax registration to 757.569.6055
DO NOT INCLUDE CREDIT CARD INFO!
Call 757.569.6058 to make a payment
Mail all completed forms with your payment to:
Kids College, Paul D. Camp Community College
100 North College Drive
Franklin, VA 23851
Early Bird Discounts
(through June 3)
# of classes x $5
____ classes x $5 =
Other Discounts
TOTAL
IN PERSON
For Franklin
Bring your registration form & payment to the Franklin campus
of Workforce Development, Mon – Fri, 8:30a – 4:30p
For Smithfield

See Kids College website for Smithfield registration office
hours OR

Email/phone Kids College registrar to make an
appointment to register in Smithfield

DO NOT DELIVER FORMS OR PAYMENTS TO THE
SMITHFIELD CAMPUS OUTSIDE OF OFFICE HOURS OR
APPOINTMENT TIMES
STUDENT PICK-UP FORM
Student’s Name: ________________________________________________
Please complete a separate form for each child.
A parent or guardian must complete this form. List below the person(s) with permission to pick up your child
from class. Your child’s instructor/instructional assistant will only release your child to the listed individual(s).
Anyone picking up your child (including yourself) will need to provide a driver’s license as proof of identity
each time you or an authorized person pick up your child.
*******************************************************************************************
I give permission for the following individual(s) to pick up my child from the 2016 Kids College Program.
I understand that a driver’s license will be required as proof of identity EVERY TIME SOMEONE PICKS UP MY
CHILD. I also understand that my child will not be released to any individual(s) not on this list.
Please print or type names clearly. Be sure to include your own name as well as the names of other guardians
or relatives. If you need to add names to this list later, please submit an amended list.
Parent/Guardian Name (please print): _________________________________________________
Parent/Guardian Signature: _____________________________________ Date: _______________
PARENT RELEASE FORM (OPTIONAL)
You only have to fill this portion out if you want your child to be allowed to sign themselves out of class
without an adult signature. READ CAREFULLY!
I give permission for __________________________________________ to leave his/her assigned Kids College classroom
and walk unattended to the parking lot of the Regional Workforce Development Center. I will not hold the Kids College
Program, the Regional Workforce Development Center, or Paul D. Camp Community College responsible in any way for my
child's welfare after he/she leaves the classroom.
Parent/Guardian Name (please print):
________________________________________________________________
Child's Name: _______________________________________________
Date: __________________________
Parent/Guardian Signature: ________________________________________________________________
This release form will remain on file and may cover any of the courses for which your child is registered for the remainder
of this summer’s Kids College program. Please contact us immediately if your preference on this matter changes.
RELEVANT HEALTH CONDITION INFORMATION
1. Does your child take any medications?
Please List:
□ NO
___________________________________________________________________
2. Does your child have any allergies?
Please explain:
□ YES
□ YES
□ NO
____________________________________________________________________
3. Does your child carry a respirator, EpiPen or other medical device?
Please explain:
□ NO
____________________________________________________________________
4. Does your child have any special learning or behavioral needs?
Please explain:
□ YES
□ YES
□ NO
____________________________________________________________________
EMERGENCY CONTACT INFORMATION
Telephone number(s) where you can be reached during class session(s):
____________________________
Alternate Phone: ____________________________
Emergency Contact: ______________________________ Relationship: ________________ Phone No.: _____________
Emergency Contact: ______________________________ Relationship: ________________ Phone No.: _____________
ASSUMPTION OF RISK AGREEMENT
I agree that as a participant in the Kids College program at Paul D. Camp Community College (the “College”) scheduled for summer
2016, I am responsible for my own behavior and well-being. I accept this condition of participation, and I acknowledge that I have been
informed of the general nature of the risks involved in this activity, including, but not limited to Kids College program activities.
I understand that in the event of accident or injury, personal judgment may be required by Kids College staff or College personnel
regarding what actions should be taken on my behalf. Nevertheless, I acknowledge that the College and/or Kids College personnel may
not legally owe me a duty to take any action on my behalf. I also understand that it is my responsibility to secure personal health
insurance in advance, if desired, and to take into account my personal health and physical condition.
I further agree to abide by any and all specific requests by the College and Kids College staff for my safety or the safety of others, as
well as any and all of the College’s and Kids College’s rules and policies applicable to all activities related to this program. I understand
that the College reserves the right to exclude my child’s participation in this program if my participation or behavior is deemed
detrimental to the safety or welfare of others.
In consideration for being permitted to participate in this program, and because I have agreed to assume the risks involved, I hereby
agree that I am responsible for any resulting personal injury, damage to or loss of my property which may occur as a result of my
participation or arising out of my participation in this program, unless any such personal injury, damage to or loss of my property is
directly due to the negligence of the College and/or Kids College staff. I understand that this Assumption of Risk form will remain in
effect during any of my subsequent visits and program-related activities, unless a specific revocation of this document is filed in writing
with the Kids College director, at which time my visits to or participation in the program will cease.
I acknowledge that I have read and fully understand this document, and that I agree to the terms and conditions of this form.
My child/ward is under 18 years of age and I am hereby providing permission for him/her to participate in this program, and I agree to
be responsible for his/her behavior and safety during this program.
_______________________________________________________________________________
Parent/Guardian Signature
________________
Date
FIELD TRIP PERMISSION FORM
I, (parent name) ____________________________________________________ ____ do hereby willingly give permission for my
child, __________________________________________, to participate in all field trips that are part of my child’s registration.
PLEASE CHECK ALL THAT APPLY. Please make sure that the date of your child’s field trip is correct. YOUR CHILD WILL BE UNABLE
TO PARTICIPATE IN ANY FIELD TRIP WITHOUT THIS PERMISSION SLIP.
√
Course
Date
Time
Field Trip Location
Animal Close Encounters
July 1
9:00a – 4:00p
Richmond Metro Zoo
July 25 – July 29
9:00a – 4:00p
IOW Museum & Smithfield area
Happy Planting!
Mythology Madness
Loving and Grooming Days
Loving and Grooming Days
Horseback Riding Camp (1 day)
June 23
July 1
July 8
August 5
July 11
8:30a – 12:30p
8:30a – 12:30p
Chrysler Museum
7:30a – 12:00p
7:30a – 6:00p
Ballyshannon Equestrian Center
Horseback Camp (1 day)
August 8
7:30a – 6:00p
July 18 – July 22
7:30a - 12:00p
8:30a – 4:30p
1:00p – 5:00p
1:00p – 5:00p
9:00a – 2:00p
8:30a – 12:30p
Children’s Museum, Portsmouth
STAT! Nursing/Health Career Academy
July 14
July 14
August 1
July 26
August 4
Pond Paddle I & II
Pond Paddle I & II
Pond Paddle I & II
Rollin’ on the River (2.5)
Rollin’ on the River (2.5)
Rollin’ on the River (5)
June 22
July 14
August 3
June 29
July 29
July 7
8:30a – 12:30p
Darden Mill Pond
8:30a – 12:30p
Area Rivers*
*Location may vary due to river
conditions.
Rollin’ on the River (5)
August 12
8:30a – 1:30p
Intro to Stand Up Paddle Boarding
Intro to Stand Up Paddle Boarding
Intro to Stand Up Paddle Boarding
June 24
July 21
August 10
8:30a – 12:30p
Chowan river beaches
July 18 – July 19
9:30a – 2:30p
Suffolk Center for the Cultural Arts
Get Hooked! Crocheting 101
July 13
2:00p – 5:00p
Suffolk Center for the Cultural Arts
Get Hooked! Crocheting 101
July 20
2:00p – 5:00p
Suffolk Center for the Cultural Arts
Get Hooked! Crocheting 101
July 27
2:00p – 5:00p
Suffolk Center for the Cultural Arts
So You Think You Can Dance?
July 13
10:30a – 1:00p
Suffolk Center for the Cultural Arts
So You Think You Can Dance?
July 20
10:30a – 1:00p
Suffolk Center for the Cultural Arts
So You Think You Can Dance?
July 27
10:30a – 1:00p
Suffolk Center for the Cultural Arts
Finding Smithfield
Local gardens and/or farms
Horseback Riding Camp (week)
KC Science Fest
Panera Bakers in Training
Panera Bakers in Training
Sew Fun! KC Stitch Club
Comic Creations!
________________________________________________________________________
Parent/Guardian Signature
Suffolk Panera
Suffolk Panera
Franklin Wal-Mart
Franklin Fire Department
_____________________
Date
NETWORK USER AGREEMENT FORM
As a user of the Paul D. Camp Community College computer network, I hereby agree to comply with the rules
stated in the PDCCC Kids College Acceptable Use Agreement, communicating over the network in a responsible
fashion while honoring all relevant laws and restrictions. Should I knowingly commit any violation, my access
privileges may be revoked, and college disciplinary action and/or appropriate legal action may be taken.
Printed Student Name _______________________________________________
Date ___________________________
As the parent or legal guardian of the minor student signing above, I have read the Acceptable Use Agreement.
I understand that this access is designed for educational purposes. I also recognize that Paul D. Camp
Community College does not restrict access to any online material and I will not hold the college responsible for
materials viewed or acquired on the network. Further, I accept full responsibility of my child’s behavior.
I hereby give permission to PDCCC to grant computer and network access to my child and certify that the
information contained on this form is true and correct.
Parent Signature ___________________________________________________________________________
Printed Parent Name
____________________________________________________________________
Date ___________________________
STUDENTS WILL NOT BE PERMITTED COMPUTER ACCESS UNTIL THIS FORM IS SIGNED
AND RETURNED. NOT VALID WITHOUT PARENT SIGNATURE.