Summer Reading Registration and Permission Form

Welcome to our 2022 Summer Reading Signup!

2022 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 on the Kiowa County Courthouse lawn in Eads, Colorado. See you there! Dates: June 29 and July 6, 13, & 20, 2022 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 2022-2023 school year? (required) *

First Additional Child: Name, Age, Grade (2022-2023 school year)

Please list additional child's Name, Age, and what Grade they will be in for the 2022-2023 school year.

Second Additional Child: Name, Age, Grade (2022-2023 school year)

Please list additional child's Name, Age, and what Grade they will be in for the 2022-2023 school year.

Third Second Additional Child: Name, Age, Grade (2022-2023 school year)

Please list additional child's Name, Age, and what Grade they will be in for the 2022-2023 school year.

Name of Parent or Guardian (required) *

Full Mailing Address (required) *

Mailing Address, City, Zip Code

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

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

Questions, comments, concerns?

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

BY SUBMITTING THIS FORM
I give permission for my child to attend the 2022 KCPLD Summer Reading Program on June 29 and July 6, 13 & 20, 2022, from 1:00-2:30 PM on the Kiowa County Courthouse lawn in Eads, Colorado. Should inclement weather occur, I understand the program will be moved inside the Courthouse building.

I give permission for my child to interact in close proximity with multiple children in an outdoor and/or indoor 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 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, 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’s likeness.

Name *

First

Last

Please type your first and last name to electronically sign the form and indicate your agreement to the above.

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