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Winter Break Camp 2019-20 (SMSD)

  1. JCPRD logo

  2. Below list additional, current, PreK siblings you wish to enroll in Winter Break Camp.

  3. Days of Attendance*

  4. Current JCPRD OST Participant*

    Is child currently enrolled in a JCPRD OST program?

  5. JCPRD is committed to making reasonable accommodations as required by the Americans With Disabilities Act. Requests must be made two weeks or ten working days prior to the start of the program. Please indicate what accommodations are needed.

  6. For JCPRD Staff Only

  7. For JCPRD Staff Only

  8. Electronic Signature Agreement*

    I understand that my payment will be processed at the time of enrollment using my current credit/debit card on file, and that ALL FEES ARE NON-REFUNDABLE and NON-TRANSFERABLE. If my child is not currently enrolled in a JCPRD OST program, I understand that I must call the Registration Office (913.831.3359) with payment information before my enrollment will be processed.

  9. Electronic Signature Agreement*

    JCPRD WAIVER STATEMENT: "The undersigned states that he/she understands that the Johnson County Park and Recreation District is not and shall not be responsible for or liable for any illness, or injury to person or damage to property resulting from the program in which the undersigned is enrolling or being enrolled or from his/her participating in said program, and the participant and the undersigned, if the participant is a minor or under other legal disability, hereby forever releases and holds harmless the said Johnson County Park and Recreation District, it’s employees, agents and representatives from any and all claims of any kind that the participant, or the undersigned or their respective heirs, executors, administrators, or assigns may have or claim to have resulting from participation in said program. NOTICE: By enrolling in this program you hereby acknowledge the Johnson County Park and Recreation District can and may photograph and/or video tape program participants and then use such images, without payment or any other consideration, for purposes of publicizing District parks, facilities, programs or services, or for any other lawful purpose. By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

  10. Electronic Signature Agreement*

    SCHOOL DISTRICT WAIVER: We, the undersigned, parents of child above, acknowledge that the School Age Child Care Program operated by Johnson County Park and Recreation District (“Park District”) is not a program operated or controlled by Shawnee Mission School District, Johnson County, State of Kansas (the “School District”); that the School District is only a lessor of space and has no responsibility whatsoever for the administration or operation of the program, for the selection of any employees to operate the program by the provider thereof, or for any act or omission which may occur while any child is going to, participating in, or going from the program. We, further, acknowledge that the program has not been approved by the School District and will not be supervised by the School District. We agree that the School District shall not be liable for any act or failure to act on the part of the Park District, its agents or employees, and we do waive any liability of the School District with reference thereto and promise and agree to save, and hold the School District free and harmless from any and all loss, of any and all nature or kind whatsoever, as the same may relate to any injury suffered or damage sustained by our child(ren) participating in the program or by us. By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

  11. Leave This Blank:

  12. This field is not part of the form submission.