1. technology and computing
2. consumer electronics
3. telephones
4. mobile phones

Please check which week or weeks you would like your child to participate in the K.I.T.E. program.
Children ages ____3-6 years 9:00-12:00
____April 6-10 ____June 22-26
____ ages 7-12years 1:00-4:00
____July 20-24
$70.00
Make Check payable to:
enTECH
Child’s full name: ______________________________
Child’s Age/DOB:______________________________
Please Return Registration to:
enTECH at Spalding University
Attention: Mary Kaye Steinmetz
845 S. Third Street
Louisville, Ky. 40203
Nickname: ___________________________________
Mother’s name:________________________________
Father’s name:________________________________
Custody status (circle one):
both parents
mother
father
guardian
Child resides with: __________________________________________________
Custody Issues to be aware of:_________________________________________
Home address: _____________________________________________________
_____________________________________________________
Home phone: ______________________________________________________
Other phone #1: ____________________________________________________
Other phone #2: ____________________________________________________
Email: ____________________________________________________________
IN CASE OF EMERGENCY:
First call to: ___________________________________ __________________
(name)
(phone number)
If this person cannot be reached, please call these persons in the following
order:
#1 _______________________ ___________________ _______________
(name)
(relationship)
(phone number)
#2 _______________________ ____________________ ______________
(name)
(relationship)
(phone number)
#3 _______________________ ____________________ ______________
(name)
(relationship)
(phone number)
Medical Diagnosis: ________________________________________________
_________________________________________________________________
_________________________________________________________________
Allergies: ________________________________________________________
_________________________________________________________________
_________________________________________________________________
Medications given at home:
Name
Dosage
For
Time
Medications to be given at K.I.T.E.:
Name
Dosage
For
Time
If you would like the K.I.T.E. staff to contact to contact your providers, please ensure
the contact information is provided 14 days in advance.








Pediatrician: ________________________________ __________________
(name)
(phone number)
Neurologist: _________________________________ __________________
(name)
(phone number)
Other specialists: _________________________________ ______________
(name)
(phone number)
Physical Therapist: ________________________________ ______________
(name)
(phone number)
Speech Therapist: _________________________________ _____________
(name)
(phone number)
Occupational Therapist: _________________________________ _________
(name)
(phone number)
Behavior Therapist: ______________________________________________
(name)
(phone number)
Other specialists: _________________________________ ___________
(name)
(phone number)
My child is allergic to:
Medications
Foods/Drinks
Environmental
Animals
My child has seizures: Yes ____ No ____ If yes, please complete following:
since children may have more than one type of seizure, fill in one section for each
type
Type 1: Please describe
seizure in detail.
How long does it usually last?
What procedure do you
1.
want followed during a
2.
seizure?
3.
At what point do you want us to call 911?
To which hospital do you want us to transport?
What does your child
usually do after a seizure?
Type 2: Please describe
seizure in detail.
How long does it usually last?
What procedure do you
1.
want followed during a
2.
seizure?
3.
At what point do you want us to call 911?
To which hospital do you want us to transport?
What does your child
usually do after a seizure?
Additional Medical information: ________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
My child receives nourishment through a G-tube: Yes __ No___
She/He will need feedings during KITE. Here is the feeding schedule:
Feeding Nourishment
Amount Special Instructions
time:
What type of diet? (ie. Gluten free, casein free, etc.)
____________________________________________________________
____________________________________________________________
Special Instructions for Snack time:
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
Favorite things:
Snack foods
Drinks
TV shows
Activities
Participation
sports
Textures
Music
Smells
Toys
Other:
Dislikes:
Snack foods
Places to go
Drinks
TV shows
Activities
Music
Participation
sports
Textures
Toys
Smells
Transitioning:
If your child has a hard time transitioning from one activity to another, or changes in
the routine, what are some suggestions to facilitate smooth transitioning?
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
What are some foods, activities, or behaviors you want to make sure are
avoided, or not allowed at all during your child’s time at KITE:
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
Communication Needs:
How does your child communicates the following:
Anger
Happiness
I love you
Discomfort
Hello
I want attention
Hunger
Desire for movement
Play with me
Thirst
Need to go to toilet
I’m scared
Injury
Want to communicate
Need help
Leave me alone
Does your child engage in any of the following behaviors (check and describe):
___ Aggression:
____________________________________________________________________
___ Property Disruption (throwing/ripping/breaking items in their environment):
____________________________________________________________________
___ Self-Injury: _______________________________________________________
___ Stereotype (rocking, head twirling, hand flapping, lining things up, etc.)
____________________________________________________________________
Please feel free to add any information that you think would be helpful,
including any information about behaviors and your methods of assisting your
child with non-productive behaviors.
This information is correct as far as I know. In the event of an emergency, I hereby give
permission to the director of the program or designee to secure emergency medical services,
including transportation and physician. I also give permission to the attending physician to
order injection, anesthesia, or surgery for my child as named above.
Parent/Legal Guardian Signature: _____________________________________________
Date: ____________
MEDIA RELEASE
The undersigned hereby grants permission and consents to enTECH’s use of the undersigned’s name,
photograph, likeness and/or quotations in promotional materials prepared by or on behalf of enTECH and/or
Spalding. For purposes of this Media Release, promotional materials includes all video, print, electronic,
internet or radio publications or advertising. Furthermore, the undersigned agrees and acknowledges that he
or she shall not be entitled to any compensation in connection with enTECH’s or Spalding’s usage of the
undersigned’s name, photograph, likeness and/or quotations in promotional materials prepared by or on
behalf of enTECH or Spalding. This Release may be revoked at any time by the undersigned in a writing
provided to enTECH
____________________________________
Signature
___________________________________________
Name (Print Clearly)
Date
INFORMED CONSENT AND RELEASE FORM
enTECH at Spalding University requires all that participate in K.I.T.E. to execute this informed
consent and release form prior to participate. By signing this form, the undersigned agrees and
acknowledges the following:
1.
I am familiar with the rules, regulations and policies of the enTECH’s K.I.T.E. program
at Spalding University (the “Facility”) and the physical activities in which I and/or my child may
participate. I understand that these activities may include, among other things, using movement
equipment and craft supplies that could result in physical or psychological illness, injury or death. My
and/or my child’s use of the Facility is voluntary and I voluntarily assume all risk of loss sustained in
connection with such use.
2.
I, together with my heirs, guardians, executors, administrators, successors and
assigns, hereby (i) waive, release, discharge and agree to indemnify and forever hold harmless
enTECH and Spalding University, their officers, trustees, employees, representatives, agents
successors and assigns from and against any and all loss, claims, demands, damages, rights of action
or causes of action (including costs and attorneys fees), direct or indirect, present or future, whether
the same be known, anticipated or unanticipated, resulting from or arising out of my and/or my child’s
use of the Facility, and (ii) covenant not to assert against enTECH or Spalding University, their
officers, trustees, employees, representatives, agents successors or assigns, either directly or
indirectly, any claim, demand, cause of action or suit for any reason whatsoever including but not
limited to the death, injury or damage to person or property resulting from my and/or my child’s use of
the Facility.
3.
I certify that I have and/or my child has health insurance coverage and will present
proof of such coverage upon request.
IN WITNESS WHEREOF, the undersigned executes this Informed Consent and Release Form as of the date
set forth below.
Name of Child
DOB (if under 18 years old)
________
Signature of Parent or Guardian
Relationship to Child
Date: _____________________________
Releases of Information For:
 Physical Therapist _______________________________________________
 Speech Therapist ________________________________________________
 Occupational Therapist ___________________________________________
 Behavior Therapist _______________________________________________
The undersigned hereby grants permission for enTECH’s K.I.T.E staff to contact the
professionals indicated in this Registration form for information on their child as it pertains to
their participation in the K.I.T.E. program.
Name of Child
DOB (if under 18 years old)
________
Signature of Parent or Guardian
Relationship to Child
Date: _____________________________