Camp KidZone Registration | Graceachild USA

Summer Camp Enrollment 2026

"*" indicates required fields

CHILD INFORMATION:

To join Camp KidZone, children must have completed Kindergarten. This helps us ensure all campers have the best experience with age-appropriate activities. Children who have not yet finished Kindergarten are not eligible to enroll.

How many children are you enrolling? Ages 5 – 10 years old qualify. If your child is younger, contact us at 540-382-9591 and ask about daycare.*

REQUIRED DOCUMENTS — NEW FAMILIES ONLY!

UPLOAD:

1. Proof of birth (BIRTH CERTIFICATE), recent immunizations, and last physical/well visit. Your child CANNOT START UNTIL RECEIVED!

2. Parents are required to obtain these documents. Camp KidZone DOES NOT REQUEST DOCUMENTS FROM THE SCHOOLS! Click this link to complete needed forms if you have not done so already for the school:
School Entrance Health Form (PDF)

— THESE MUST BE COMPLETED BY YOUR CHILD’S PHYSICIAN.

4. YOU MAY UPLOAD THEM BELOW OR SCAN & EMAIL to: contact@graceachild.org

Drop files here or

Max. file size: 1 GB.

Date you wish your child/ren to start:*

Tuition Policy: Camp KidZone tuition is continuous from the start of enrollment through the last week of camp. There are no pauses, breaks, or refunds during this period from June 1st – August 7th.

Parent/Guardian Camp KidZone Agreement:*

I understand that the Camp KidZone Program is for children ages 5 to 10 years old, with tuition set at $165 per week, per child. I understand that a 5% sibling discount is applied for additional enrolled siblings, and no other discounts apply.

I acknowledge that tuition covers a continuous 10-week program from June 1st through August 7th (end date subject to change based on the public school calendar). I understand that enrollment secures my child(ren)’s spot for the full duration of the program.

I agree that tuition is due regardless of attendance, including absences or vacations, and that no refunds or credits will be issued for any missed days.

I confirm that I have read, understand, and agree to the terms outlined above.

I agree to pay my non-refundable regostration fee of $50 per child upon enrollment (current enrolled families pay no registration fee).

Payment for the camp weeks you reserve will be processed each Thursday prior to the week of attendance. Camp KidZone does not pause or adjust tuition for absences, missed days, or vacations. Once payment has been processed, no changes, transfers, or refunds will be issued for any reason. If your child does not attend during a reserved week, it will be considered a “no show,” and tuition will not be refunded.

Where did your child previously attend childcare (please type n/a if not applicable)?

1st Child:*

Gender First Last

Date of Birth:*

What grade is your 1st child RISING into?*

2nd Child:*

Gender First “Nickname” Last

Date of Birth:

What grade is your 2nd child RISING into?*

3rd Child:*

Gender First “Nickname” Last

Date of Birth:*

What grade is your 3rd child RISING into?*

4th Child:*

Gender First “Nickname” Last

Date of Birth:

What grade is your 4th child RISING into?*

MEDICAL INFORMATION & CONSENTS:

Virginia State Licensing requires a copy of your child’s most recent physical and immunizations, and proof of birth BEFORE a child can start. For your convenience, you may click the following link to print the “VA School Entrance Form” to have your child’s pediatrician complete as necessary: Download School Entrance Form

Pediatrician's Name:*

Phone #:*

Child Illness & Communicable Disease:*

If you’re notified that your child is ill, you agree to arrange for yourself or one of your listed contacts to pick your child up within 1 hr. If your child or a member of your immediate household become ill or exposed to a Communicable Disease (CD), you agree to notify Camp KidZone within 24 hrs.

If my child is ill I agree to pick them up. I will notify the center in 24 hrs if exposed to a CD.

Emergency Medical Release & Transport:*

In the event I cannot be reached, I authorize Camp KidZone staff to act on my behalf for my child to receive emergency care, and if deemed necessary, arrange for emergency transport to the hospital of my choice.

I authorize Camp KidZone staff to provide emergency care or hospital transport as necessary.

Not authorized – Please follow specific instructions in text box below.

Hospital Preference:*

Carilion Radford

Lewis Gale Blacksburg

Medical Care After Child Leaves the Center:*

IMPORTANT NOTE: In the event your child sustains an injury while in our care but is NOT transported to the hospital or doctor from Camp KidZone, you agree to contact the main office (540-382-9591) within 24 hrs should you decide at a later time to take your child to the hospital or doctor to be evaluated. Per Virginia State Licensing Standards, Camp KidZone is mandated to report any medical treatment sought for the child’s injury after the child has been picked up from Camp KidZone.

I agree to contact Camp KidZone within 24 hrs should I seek medical care for my child after picking them up.

Allergies, Special Needs, or Medication:*

My child has no Allergies, Special Needs, or takes any Medication at this time.

Yes, I have specific details regarding my child’s Allergies, Special Needs, or Medication.

If medication needs to be administered, please click the link below to the Medicine Consent Form and have the pediatrician complete it. With the completed form, provide your child’s medicine in its original box to the director of the center. Describe any specific details in the box below.

Medication Consent Food Allergy POA Asthma POA

Sunscreen Use Authorization:*

Product Supply & Labeling:
If you would like sunscreen applied to your child as needed, please provide products that are not expired, in their original box, and labeled with your child’s full name, and date of birth. Sunscreen is not required, but we highly recommend it especially between the months of April-October, and should be a minimum SPF 30.

Prescription Creams & Lotions and Possible Adverse Reactions:
If your child requires a prescription topical, we will need a Medicine Consent form from your pediatrician. If you know of any adverse reactions your child may have to sunscreen, please provide details in the box below.

I authorize Camp KidZone staff to apply SUNSCREEN cream

I do NOT authorize the use of SUNSCREEN

Specific Instructions for Emergency Medical Care, Hospital Transport, Allergies, Special Needs, Medications and/or Adverse Reactions to topicals:

PARENT/GUARDIAN INFORMATION:

If the primary parent (1st parent) has physical and/or legal custody of the child being enrolled, please be prepared to provide copies of legal court documents stating this. Please understand that if you do NOT provide this information and you choose NOT to include the secondary parent on this enrollment form, GraceAChild is legally bound to allow the secondary parent access to his/her child after we have properly identified them to do so. We can however alert you if the secondary parent is requesting to see the child.

Who does your child(ren) live with?*

1st Parents (primary parent) Relation to Child:*

1st Paren Name:*

First Last

Full Physical Address (PO Box is not a valid address):*

Street Address City State ZIP Code

Cell Phone #

Valid Email Address Required

Employment Status*

Va state licensing requires that we obtain your current employers address and phone # if you are currently employed.

Employed

Unemployed

Employer’s Name:

Full Physical Address (PO Box is not a valid address):*

Street Address City State ZIP Code

Employer’s Phone #:

2nd Parents Relation to Child:*

2nd Parent's Name:*

First Last

Is the 2nd parent's physical address the same as the 1st parent?*

Yes

No. Please complete address information below.

Full Physical Address (PO Box is not a valid address):*

Street Address City State ZIP Code

Cell Phone #*

Email Address (Optional for 2nd parent):

Employment Status*

Va state licensing requires that we obtain your current employers address and phone # if you are currently employed.

Employed

Unemployed

Employer's Name:*

Full Physical Address (PO Box is not a valid address):*

Street Address City State ZIP Code

Employer’s Phone #:

EMERGENCY CONTACTS & AUTHORIZED PICK-UPS:

Virginia State Law requires you to provide a minimum of 2 emergency contacts OTHER THAN the parent(s), that live within 1 hour of your child’s center.

If you are new to the area, we allow you 2 weeks to establish emergency contacts. It’s extremely important that you’re available by phone at all times while your child is in our care, especially during the 2 week period of establishing emergency contacts. If this information is not provided within 2 weeks of your child’s first day of attendance, your childcare services may be interrupted until this information is provided to the center.

1st Contact:*

First Last

Relation to Child:

Cell Phone #:

Full Physical Address (PO Box is not a valid address):*

Street Address City State ZIP Code

2nd Contact:*

First Last

Relation to Child:

Cell Phone #:

Full Physical Address (PO Box is not a valid address):*

Street Address City State ZIP Code

Would you like to include additional authorized pick-ups?*

You may add up to 2 additional people “OTHER THAN” yourself and your listed emergency contacts, who may pick your child up. This is optional.

I would like to provide 1 additional authorized pick-up.

I would like to provide 2 additional authorized pick-ups.

1st Authorized Pick-Up:*

First Last

Relation to Child:

Cell Phone #:

Full Physical Address (PO Box is not a valid address):*

Street Address City State ZIP Code

2nd Authorized Pick-Up:*

First Last

Relation to Child:

Cell Phone #:

Full Physical Address (PO Box is not a valid address):*

Street Address City State ZIP Code

PARENTAL AGREEMENTS:

EARLY WITHDRAWAL AGREEMENT:*

1-week notice is required to withdraw from the program & notification must be sent through Brightwheel. Without a notice, full tuition will still be charged. Didn’t get a reply? Text Casey at 985-503-8757 to confirm receipt.

I Agree to comply with Camp KidZone’s terms of withdrawal or pay applicable tuition fees.

LATE PICK-UP AGREEMENT:*

Camp KidZone closes promptly at 5:30 PM, Monday through Friday.

Late pick-up fees will apply as follows:
• 5:31–5:35 PM — Flat $10 fee
• After 5:36 PM — $1 per minute.

Fees will be added to your account the next business day. No exceptions.

I agree to pay all applicable late pick-up fees if I or one of my listed contacts fails to pick up my child by 5:30 PM.

PHOTO CONSENT:*

Our staff loves to share photo’s on Facebook of your children engaging in fun activities, the beautiful arts and crafts they’ve created, dancing and singing, or just being plain ol’ silly nilly’s. We encourage all families to Like our Facebook page to enjoy these photo’s. We do understand the immense responsibility that comes with proper etiquette and exposure of a child, especially on social media. Therefore, all photo’s are reviewed by the center director before posting to Facebook to ensure these standards are met for each child. No child’s name is ever included in any photo’s posted. If we would like to use an awesome photo of your child for advertising purposes, we will discuss this with you ahead of time and have you sign a separate permission form.

I agree to allow photo’s of my child.

I DO NOT allow photo’s of my child.

Hold Harmless & Liability Waiver – Camp KidZone:*

I, the parent/legal guardian of the child enrolled in Camp KidZone, understand that participation in camp activities involves inherent risks. I voluntarily assume all risks related to my child’s participation in Camp KidZone programs, activities, and events.
I agree to release, waive, discharge, and hold harmless KidZone, its owners, staff, volunteers, and representatives from any and all claims, demands, actions, or causes of action arising out of or related to any injury, illness, accident, loss, or damage sustained by my child while participating in Camp KidZone, except in cases of gross negligence.
I further agree that Camp KidZone is not responsible for lost, stolen, or damaged personal property.

I acknowledge that I have read, understand, and agree to this Hold Harmless Agreement.

PARENT HANDBOOK:*

I have read and understand the Camp KidZone Parent Handbook.

Camp KidZone reserves the right to make changes to any policy, procedure, tuition rates, fees, or other processes and information in this parent handbook, rate sheets, or our enrollment forms without prior notice. We reserve this right to maintain licensing compliance, stability, and integrity of the programs, and for the safety and security of the children & families enrolled in our programs, and for the staff that our company employs.

Camp KidZone Handbook

Parent Electronic Signature for Enrollment:*

First Last

Date Enrollment Submitted:*

PAYMENT ASSISTANCE INFORMATION:

Childcare Payment Assistance ~ Please choose one of the following:*

Please note: Foster care and Swift Start assisted families are responsible for paying tuition upfront and for securing reimbursement from their assistance provider.

I DO NOT receive state subsidy assistance, foster care, or Swift Start assistance.

I am currently approved and receiving subsidy childcare assistance.

I am currently on the wait list for subsidy assistance. STOP! You will be responsible for ALL fees and tuition until approved.

My child is part of the foster care system.

I am currently approved through Swift Start.

Important Note for DSS Families

DSS covers the full week of tuition; therefore, there is no weekly balance due from families.

Please ensure that your payment information is set up in Brightwheel upon receiving your invitation so that your child’s registration fee can be processed. Failure to set up payment may result in disenrollment from the program.

DSS may or may not cover the registration fee. If DSS does not pay the registration fee, the parent or guardian is responsible for a $50 registration fee per child.

Any monthly co-fees, if applicable, are determined by Social Services. Please contact your DSS worker to confirm whether a co-fee applies to your child.

Which county are you receiving assistance from:*

Montgomery County

Radford City

Giles County

Pulaski County

Floyd County

❌ Refunds & Withdrawals

Camp KidZone does not offer tuition adjustments or refunds for absences, missed days, vacations, or no-shows. All payments are final once processed.
All tuition and fees are non-refundable once processed.
Refunds are granted only in cases of injury occurring in our care or documented family hardship.
A one-week written notice is required for withdrawal. Failure to provide notice will result in full tuition charges.

Payment Policy Agreement*

By typing my name below, I acknowledge that I have read and agree to the payment policies in this agreement. I understand that I am responsible for all tuition and fees incurred upon enrollment and while my child is enrolled in Camp KidZone. I authorize Camp KidZone to process all due charges through Brightwheel using the bank account information I have provided. I understand that failure to comply with these policies may result in late fees, suspension, or termination from the program.

Electronic Signature for Payment Agreement:*

First Last

After clicking submit you should be re-directed to a “confirmation” screen. If you remain on the same screen, please scroll back through the form to complete highlighted areas and resubmit.