KICK Tuition Assistance Application

KICK Tuition Assistance Application
Tuition assistance will be based on the Federal Income Eligibility Guidelines.

Free and Reduced Lunch automatically qualifies your camper for tuition assistance. A letter from the Department of Food and Nutrition or from your child's school is required with each application. Please use the upload file button at the beginning of this form.

If you are not on free and reduced lunch but qualify under the Federal Income Guidelines, please contact Riley Dvorak at 319-398-7772 for more information.

Tuition Assistance is available on a first come, first serve basis and is limited to one camp, per child, per school year (July 1st - June 30th).

Applications must be received at minimum three business days prior to the start date of the desired camp. Completing this form does not guarantee your child a spot in the camp.
File Upload - Free and Reduced Lunch Letter

Allowed file types: .pdf, .doc, .docx
Cancelof
Camp Preference List
Health/Medical Release Information
Camper's Name

First NameLast Name
Date of Birth

MonthDayYear
Gender
Expected Graduation Year
Parent/Guardian Name

First NameLast Name
Parent/Guardian Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Would you like to receive text messages?
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Alternate Emergency Contact Name

First NameLast Name
Alternate Emergency Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
Insurance Information
Provider & Policy Number
List any medical conditions (N/A if not applicable)
List any medications the child is taking (N/A if not applicable)
If the name minor child is in need of medical attention, as the result of either illness or injury, I do hereby give my permission for Kirkwood Community College to provide, or see that the necessary care is provided. Additionally, I give the College permission to submit my medical insurance information to any medical provider caring for the named minor child.
Signature of Parent/Guardian*
Date*
Should be Empty:

KICK Tuition Assistance Application

Health/Medical Release Information