Form Center

2. All forms must be completed in full and submitted and enrollment fee paid before your child is registered in the program. Please note, a separate form must be completed for each child. All information is required.

4. Child’s Name*
5. Birthdate*
   Birthdate
6. Age as of June 12, 2023*
8. Parent/ Guardian Name(s)*
10. Home Address*
12. City*
13. State*
14. Zip*
16. Siblings in Kids R.O.C.K.?*

    1. Yes

    1. No
17. Name(s) of Siblings in Kids R.O.C.K.
19. VMCC Family Membership?*

    1. Yes

    1. No
20. T-Shirt Size*

    1. Youth Small
    2. Youth Medium
    3. Youth Large

    1. Adult Small
    2. Adult Medium
    3. Adult Large
22. Parent/Guardian Contact Information

    Please be sure to indicate the parent’s name. Primary Parent means that in case of child's illness/emergency, this would be the parent most readily available.

24. Primary Parent/Guardian Name*
25. Primary Parent/Guardian Cell Phone*
27. Primary Parent/Guardian Home or Work Phone*
28. Primary Parent/Guardian Email*
30. Secondary Parent/Guardian Name*
31. Secondary Parent/Guardian Cell Phone*
33. Secondary Parent/Guardian Home or Work Phone*
34. Secondary Parent/Guardian Email*
36. In Case of Emergency

    I authorize the following people (not listed above) to be contacted and/or pick up my child. Names and phone numbers of two people must be provided.

38. 1st Emergency Contact Name*
39. 1st Emergency Contact Relationship*
40. 1st Emergency Contact Phone*
42. 2nd Emergency Contact Name*
43. 2nd Emergency Contact Relationship*
44. 2nd Emergency Contact Phone*
46. Authorized Pick up

    Who is authorized to pick up your child? Any person not listed above will not be allowed to pick up your child from Kids R.O.C.K. The primary and secondary parent/ guardian and emergency contact will be included in this list unless otherwise noted. If you need more space, please contact us directly.

48. Name
49. Name
51. Name
52. Name
54. Who cannot pick up your child?

    We must have a court order on file to stop non-custodial parents from picking up a child.

56. Name
57. Name
59. Medical Information
61. Child’s Name:*
63. Does your child have any health conditions that the staff of Kids R.O.C.K. should be aware of?*

    If your child has any medical or emotional conditions, an ICCP form must be filled out as well. Please email Kids R.O.C.K. directly if one needs to be completed.

    1. Yes

    1. No
65. Please Describe
67. Is your child on medications?*

    1. Yes

    1. No
69. What medications?
71. Does the medication need to be administered while at Kids R.O.C.K.?

    If your child needs medication(s) administered while at Kids R.O.C.K., you will need to fill out and submit a medication permission form. Please complete the medication permission form.

    1. Yes

    1. No
73. Are there any activities that your child may not participate in?*

    1. Yes

    1. No
75. What Type of Activities
77. Are there any behavioral problems that staff should be aware of?*

    1. Yes

    1. No
79. What Behaviors
81. Do you carry family/hospital insurance?*

    1. Yes

    1. No
83. Carrier
84. Policy/Group Number
86. Primary Clinic*
87. Primary Physician*
89. Address*
90. Telephone Number*
92. Primary Clinic
93. Primary Physician
95. Address
96. Telephone Number
98. Kids R.O.C.K. Contract Agreements
100. General Travel/Activity Authorization*

     I give my permission for my child to leave the facility for travel with City of Inver Grove Heights vehicles or bus for the following reasons - transporting child: 

     • To obtain medical attention
     • To Inver Glen Library
     • To and/or from field trips, including Inver wood Golf Course

     I give my permission for my child to leave the facility for the following reasons: 

     • Walks around the Community Center premises
     • Walks to and from Inver Glen Library
     • Walks/bike rides within the City of Inver Grove Heights

     1. I agree.
102. Emergency First Aid*

     The only aid measure taken at the center are as follows: 

     • Bump or bruise: Apply ice if needed.
     • Splinter: First Aid by qualified staff member.
     • Cut or scratch: Clean with soap and water and attend to as needed.
     • Nosebleed: Apply Kleenex with pressure. If further care is needed, we will notify a parent/guardian.

     1. I understand.
104. Emergency Medical Care*

     This authorizes the staff of the Inver Grove Heights Parks and Recreation Department, Kids R.O.C.K. program to secure emergency medical care for my child when I/we cannot be immediately reached at the time of emergency. I will be responsible for the emergency medical charges upon receipt of statement.

     1. I agree.

106. By signing below, I acknowledge that I have read, understood, and agreed to the program policies of the Kids R.O.C.K. Program by agreeing/understanding each policy as well as signing below.

     By typing your name below, you agree and acknowledge that 

     • Your application will not be signed in the sense of a traditional paper document
     • 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
     • You may still be required to provide a traditional signature at a later date
108. Parent/Guardian Electronic Signature*
109. Date*
     Date

111. It is suggested to receive an email copy of this submitted form for your records.

Leave This Blank:


113. 1. Receive an email copy of this form.
114. Email address

     This field is not part of the form submission.

115. Submit

* indicates a required field