Summer Reading Registration and Permission Form

Welcome to our 2023 Summer Reading Signup!

2023 Summer Reading Registration & Permission Form

Please complete this form and agree to the terms before submitting. If you have more than one child to register, please use the boxes labeled "additional child" to enter their information. Sessions will be held at the Kiowa County Courthouse in Eads, Colorado. See you there! Dates: June 28 and July 5, 12, & 19, 2023 Time: 1:00-2:30 PM

Your Child's First & Last Name (required) *

Your Child's Age (required) *

What grade is your child going to be in for the 2023-2024 school year? (required) *

1st Additional Child First & Last Name

1st Additional Child Age

Grade in 2023-24

2nd Additional Child First & Last Name

2nd Additional Child Age

Grade in 2023-24

3rd Additional Child First & Last Name

3rd Additional Child Age

Grade in 2023-24

Name of Parent or Guardian (required) *

Mailing Address (required) *

City (required) *

State (required) *

Zip code (required) *

Parent or Guardian's Cell Phone Number (required) *

To be used in case of emergency and for Summer Reading notification purposes.

Parent or Guardian's Email Address

This is for Summer Reading notification purposes only.

Is any child listed above allowed to borrow items from the Library? (required) *

If you answer 'Yes', you are agreeing that your child can borrow library items each week during the program, and that you are responsible for: ensuring items are taken care of; items are returned; and that you will to pay any/all fines/fees charged on your account for late, damaged, and/or lost items.

Does any child listed above have allergies to foods, bee stings, grass, etc.? (required) *

If you answered 'Yes', please provide allergy details here:

Special Needs / Need-to-Know-Concerns / Questions / Comments?

Feel free to contact us at 719-438-5581 or email kcpld.eads@gmail.com for assistance.

I give permission for my child(ren) to leave the courthouse area without adult supervision when each SRP session is over (required): *

Please name any/all who have permission to pick up your child(ren) from SRP. If not applicable, write n/a (required) *

Your Name *

First

Last

Please type your first and last name to electronically sign the form and indicate that all of the above information is correct, and that you agree to all the terms and conditions outlined on this form when you submit your registration.

By Submitting this Form:

I give permission for my child(ren) to attend the 2023 KCPLD SRP on June 28 and July 5, 12 & 19, 2023, from 1:00-2:30 PM at the Kiowa County Courthouse in Eads, CO. I understand the program will be held both inside the building & outside on the lawn.
I give permission for my child(ren) to interact in close proximity with multiple children in an indoor and/or outdoor area. I understand that this program involves exercise, movement, and being outdoors. I understand the Kiowa County Public Library District, and its staff and volunteers, are not liable for potential injuries. I agree that my child(ren) can participate in outdoor activities, as well as walk to other locations within Eads, CO (with library staff and volunteers present) to attend special events. I understand that KCPLD will notify me by note, phone, text, and/or email to inform me when and where a special event will occur.
KCPLD has my permission to photograph and/or videotape my child(ren), to use the pictures and/or videos for marketing purposes, and to post them on our website or social media sites like Facebook. I understand that no compensation of any kind will be paid now, or in the future, for the use of my child(ren)'s likeness.

Name