Parent/Guardian Information

If different than child above

Parent/ Guardian #2

If different than child above

Emergency Contact Information

Enrollment Information

(You don't have to come all 5 days, but must sign up for the same number of days week to week)

Snacks & Drinks

We will provide 1 snack each day upon arrival to Quantum. The policy below applies to extra Snacks & Drinks available for purchase in our Pro Shop.

Pick Up Authorization

Note: Please include emergency contacts if applicable. Students will not be released to anyone other than those on this list. Photo identification may be required from anyone other than a parent guardian

Health Record

Please write N/A if there are none.
Please write N/A if there are none.
Every camper is required to have an updated immunization record on file in order to receive care. You may provide this later if you do not currently have it available.

Mission to Learn policy requires that all clients have a credit or debit card on file for payment purposes. Your Credit/Debit Card information will be secure and can only be charged under the terms you specify below.

By providing us with your Credit/Debit Card Information, you authorize Mission to automatically charge your card on a weekly basis if another payment is not secured unless full payment is provided. Cards will be run each Friday morning for the following week. Parents will be immediately notified if the card on file cannot adequately charge fees. Payment must be completed by 5 p.m. on Friday to secure the child's spot for the following week.

If the Credit/Debit Card information on file changes for any reason, you must notify Mission as soon as possible. We will maintain a clear record of all payments and charges. An email receipt will be sent to you as soon as the payment goes through.

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  1. I give permission for my child to participate in Kids Camp activities such as group led enrichment, movies, outdoor play, etc. at Mission to Learn.

  1. I give permission for my child to be included in pictures or other publicity connected with the camp, including Instagram, Facebook and other social media platforms.

  1. I understand that full payment must be made by 5 p.m. the Friday prior to the start of the week for my child to participate.

  2. If my child is not picked up by the designated time, a $35 fee will apply for each occurrance. A parent may upgrade from half-day to full-day if space is available.

  3. I understands field trips will be offered throughout Kids Camp.

  4. I am aware of the nature of this activity and I hereby assume responsibility for the participant listed above to participate. I acknowledge that, while not common, any activity that involves height and motion (such as bounce houses, tumbling and stunting) involves risk of injury ranging from minor (bruises and sprains) to more serious and catastrophic injuries. I will not hold Mission to Learn Academy LLC or its employees responsible in the case of accident or injury as a result of this participation. I understand that this completed form must be in the possession of Mission to Learn prior to participation in any program. If, at any point, I have a question or a concern regarding the safety of my child or the intent of the program, I will contact the owner, manager or instructor immediately. I also allow the participants listed to be photographed and videotaped for publicity and advertising purposes only.

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Students will be transported on the Quantum Bus to and from field trips, Immanuel Lutheran, Round Grove Pick Up, & Greenfield Schools. Students are required to wear seatbelts and follow bus rules at all times. Parents will be notified and have the option to decline field trips and transportation for field trips at any time. Students who do not follow the bus rules will receive a warning followed by a parent notification. Those who continue to have problems will be removed from the bus and will need to provide their own transportation. For a full list of bus procedures and rules, please contact the Kids Camp director.

I grant permission for my child to attend Field Trips at Quantum Athletics LLC anytime during the 24-25 school year.

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Card Information