COLLEGE BOUND FOR KIDS (CBFK)
After School Program
COLLEGE BOUND FOR KIDS (CBFK) - - REGISTRATION/EMERGENCY FORM

THIS FORM NEEDS TO BE COMPLETED AND FILLED OUT THE FIRST DAY YOUR CHILD ENTERS THE COLLEGE
BOUND FOR KIDS PROGRAM.
CONSENT TO TREATMENT OF MINOR AND AUTHORIZATION TO “COLLEGE BOUND FOR KIDS” TO GIVE SUCH CONSENT.
* Required Field
*
CHILD'S NAME:
The undersigned, as parent or legal guardian of the child registered on this form, hereby authorizes College Bound for Kids (CBFK) and its
Delegated Leaders and Directors to consent to any medical and hospital care to be rendered to said Minor upon advice of a licensed
Physician.  This authorization is given pursuant to the provisions of Section 25.8 of the Civil Code of California.  It is understood that if time
and circumstances reasonably permit, College Bound for Kids will endeavor, but is not required, to communicate with me prior to such
treatment.  The undersigned further agrees that CBFK and its Designated Leaders and Directors are not legally or financially liable for any
claim arising from any consent given in good faith in connection with such diagnosis or advised treatment.  This authorization and consent
of treatment of minor is given to CBFK in connection with any authorized event.

PLEASE NOTE: College Bound for Kids does not carry accident insurance on program participants.  All expenses
incurred in the treatment of injury due to accidents will be the responsibility of the parent, guardian or their assigned
insurance carrier.
Electronic Signature of
Parent/Guardian :
*
 *
Date:
Medical Insurance Company:
Policy #:
Family Physician:
Phone:
PERMISSION TO PARTICIPATE IN THE COLLEGE BOUND FOR KIDS PROGRAM.
*
to participate in the
I do hereby give permission for my child
Bound for Kids program.  I understand the risk involved in respect to such a program and will assume responsibility and
waive all rights to any liability claim against College Bound for Kids or its agents for injuries incurred in connection with
said program.  I further certify that my child is in good health and may participate in said program.
*
Electronic Signature of
Parent/Guardian :
*
Date:
EMERGENCY INFORMATION:
*
*
Names of Minor:
 Birthday
*
*
 Zip:
*
Address:
City, State:
At least one Parent or Guardian's full Contact Information is Required
*
 Parent or
Guardian's Name:
 Parent or Guardian's
Place of Employment:
 Parent or Guardian's
Home Phone:
Parent or Guardian's
Work Phone:
 Parent or Guardian's
Cell Phone:
 Parent or Guardian's
Drivers License No.:
Email Address:
Parent or
Guardian's Name:
 Parent or Guardian's
Place of Employment:
 Parent or Guardian's
Home Phone:
Parent or Guardian's
Work Phone:
 Parent or Guardian's
Cell Phone:
 Parent or Guardian's
Drivers License No.:
Email Address:
*
Emergency Contacts: Emergency Contact Information is Required
Name:

Name:
Relationship:

Relationship:
 Phone:

Phone:
Child's Name:
Age:
 Grade:
Child's School:
College Bound for Kids Release/ Registration Form
*
Who will be Responsible for picking up the child?
Alternate person(s) authorized to pick up child:
Please list any other family members who participate in the program:
List information in the following order: Name, Relationship, Phone Number
Name:

Name:

Name:
 Relationship:

Relationship:

Relationship:
 Phone Number:

Phone Number:

Phone Number:
Release of Liability
I hereby release and hold harmless College Bound for Kids, its agents, employees, officers, directors, sponsoring
groups or agencies from any and all liability which may result from my child’s participation in the CBFK program.  I
understand that payments are due in full on the 1st of the month or by the 1st day of each week, and I have seen the
payment schedule for late payments.  I am also aware of the $40 additional fee for any returned checks.  If my child
cannot conform to the structure of the program, I will be asked to remove him/her from the program and will not be
issued a refund. College Bound for Kids has a NO REFUND POLICY; there will be no exceptions.  We do not give credit
or make-up days for your child’s absence.  Parents are responsible for the entire monthly/weekly fees regardless of
holidays, absences, vacations or payments made by third parties. CBFK is not responsible for lost or stolen items.
*
 Electronic Signature of
Parent/Guardian :
*
Date:
CBFK staff has our permission to take whatever steps they deem appropriate to obtain medical care for our child in the
event of illness, accident, or injury.  In this connection, we understand that they will attempt to contact us and that, if they
find it necessary, they will call the child’s doctor, or another doctor, call an ambulance, or have our child taken to a
hospital in the company of a staff member, as they deem appropriate.  We, the parents/guardians agree to be
responsible for any expenses incurred in obtaining such medical care, and we hereby release College Bound for Kids
from all liability in connection with your actions pursuant to authorization.
*
 Electronic Signature of
Parent/Guardian :
*
Date:
Parent Consent Release Form
CBFK staff has permission to access my child’s homework/report cards/class schedules, grades/test scores and/or
conference with teachers to better support his/her academic achievement. .  
*
 Electronic Signature of
Parent/Guardian :
*
Date:
Photography
I authorize College Bound for Kids to use my child’s photograph for the purpose of the website, advertisement, display,
or educational purposes.  
Electronic Signature of
Parent/Guardian :
Date:
Release without a signature – (OPTIONAL – PLEASE READ CAREFULLY)
I hereby authorize College Bound for Kids, its employees, officers, and directors to release my child without a
parent/guardians signature from the program to walk or take public transportation home. I hereby hold them harmless
from any and all liability resulting from my child’s dismissal from the program.
Electronic Signature
of Parent/Guardian :
Date:
(OPTIONAL)
Credit Card Transaction Form
COLLEGE BOUND FOR KIDS
(323) 445 – 8285     (323) 898-7626     Fax: (323) 290-2209
* Required Field
*
*
 Childs name:
 Grade:
 School:
*
*
Parents Name:
 Work Phone:
 Home Phone:
Credit Cardholder’s Information:
*
Charge My:
 Visa:
 Mastercard:
 *
Todays Date:
*
*
Credit Card Number:
 Expiration Date:
*
 *
Monthly/Weekly fee(s):
Payment(s):
Registration
 Total:
AUTOPAY- charge per month/week your child attends the CBFK program
*
 Credit Card Billing Address Line 1:
Line 2:
*
 *
 Zip:
City, State:
*
Phone Number:
 Fax:
*
 Electronic Signature
of Card Holders name:
* A $4.00 transaction fee will apply for each transaction. Credit Card payments can also be made via fax to
(323) 290-2209.