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REGISTRATION FORM

Parent's Full Name(Required)

Which Program Are You Registering For?(Required)

Program Enrollment (Select all that apply)(Required)

Before School Care

After School Care

School Holidays

Teacher Workdays

Summer Camp (Coming Soon)

Days Needed

Monday

Tuesday

Wednesday

Thursday

Friday

Transportation Needed?(Required)

Yes

Child's Full Name(Required)

Preferred Name (If Different)

Gender (Optional)

Male

Female

Non-binary

Prefer not to answer

Self-describe

Child's Age (Required)

Child's Grade(Required)

Teacher (if known)

Child's School(Required)

Home Address(Required)

DOB(Required)

Month

Day

Year

Phone(Required)

Email(Required)

Parent/Guardian #2 Name (Optional)

Parent/Guardian #2 Relationship to Child (Optional)

Parent/Guardian #2 Phone (Optional)

Parent/Guardian #2 Email (Optional)

Emergency Contact Name & Number(Required)

Emergency Contact #2 Name & Number (Optional)

Authorized Pick Up List (Name, Relationship, Phone)

List name, relationship and phone number. Photo ID required for first time pick-ups.

Known Food Allergies(Required)

Medical Conditions / Medications(Required)

Does your child have any of the following? (Select all that apply)(Required)

None

IEP

504 Plan

Behavioral Support Plan

Other

What activities does your child enjoy? (Select all that apply

STEM

Reading

Arts & Crafts

Sports

Music

Dance

Drama

Technology

Outdoor Activities

Video Journalism

Other

Photo & Video Release(Required)

Yes

I authorize Radical Kidz to photograph or video my child for educational and promotional purposes.

Field Trip Permission(Required)

Yes

I give permission for my child to participate in approved field trips.

Emergency Medical Care Authorization(Required)

Yes

If I cannot be reached during an emergency, I authorize Radical Kidz to obtain emergency medical treatment for my child.

How did you hear about us?

I confirm that the information provided is accurate and I consent to my child's enrollment at Radical Kidz

By checking this box, I agree that my electronic signature has the same legal effect as my handwritten signature and I have read the Privacy Notice and consent to the collection and use of my information for enrollment and program administration.

Reach Us Directly

Address

📍 135 Wylie Street, Chester, SC 29706

📬 Mailing Address PO Box 97, Chester, SC 29706

Email

info@radicalkidz.com radicalkidz803@gmail.com

Phone

803-718-5747

Social Media

🕐 Office Hours Monday – Friday | 8:00am – 5:00pm

What can we help you with?

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