Encouraging Kids Child Online Enrollment

Encouraging Kids Family Resource Center

Child Enrollment Form
I'm interested in (check all that apply) *

After School Program Weekend Program Movie Night (Fridays) SKIT (Special Kind of Improv Theatre) ages 14-21 SKIT (Special Kind of Improv Theatre) ages 22+
Preferred Location: *

Deptford, NJ (Gloucester county) Pennington, NJ (Mercer county) Waretown, NJ (Ocean county) Beverly, NJ (Burlington county)
Mandatory NJ Dept of Children & Families 2-page acknowledgement
Mandatory NJ Dept of Children & Families 4-page risk assessment form
Child's Full Name *
Child Date Of Birth *

Month Day Year
Child's Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Parent Full Name *
Parent / Guardian Email *
example@example.com
Parent / Guardian Phone Number *

Area Code Phone Number
My Child Has Been Determined Eligible for Respite services with PerformCare NJ *

Yes No
My child's CYBER ID Number is
If applicable
I have applied for services *

I have applied for respite services through PerformCare for my child and am awaiting approval Not Applicable
I plan to apply for services *

I plan to apply for respite services through PerformCare for my child Not Applicable
My child is not eligible for respite services through PerformCare. I would like more information on private pay options. *

My child is not approved for respite services Not Applicable
Emergency Contacts:

Available to pick up your child in an emergency if you cannot be reached
Emergency Contact 1 *

First Name Last Name
Emergency Contact 1 Phone Number *

Area Code Phone Number
Emergency Contact 2 *

First Name Last Name
Emergency Contact 2 Phone Number *

Area Code Phone Number
Emergency Contact 3

First Name Last Name
Emergency Contact 3 Phone Number

Area Code Phone Number
Doctor / Clinic Information (Name, phone, address) *
Family Information
Person(s) allowed to pick up child other than parent *
Names, phone numbers
Persons NOT ALLOWED to pick up child *
Names
Primary Language spoken at home: *
Medical Declaration Statement for School-Aged Care
Current School Child Attends (Name & Town/City) *
Child's Primary Diagnosis: *
Age when diagnosed: *
Known Medical Conditions

Diabetes Convulsions/Seizures Hearing Impaired Visually Impaired Asthma Heart Condition Liver Disease High Blood Pressure Mobility Issues Feeding / Gastrointestinal Issues
Other Health Issues (Describe)
List any allergies (food or medicine) for your child *
Is your child under any medical or physical restrictions? *

Yes No
If yes, please explain:
Child's Immunization Record

Browse Files

Cancel of
**IMMUNIZATION RECORD MUST BE SUBMITTED WITH APPLICATION – NO EXCEPTIONS
Physician's Name: *
Physician's Phone Number *

Area Code Phone Number
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Parent’s insurance or medical assistance plan: Name of Insurance/Company:
Name of Insurance Company: *
Insurance Company Phone Number *

Area Code Phone Number
Insurance ID Number: *
Policy is in name of: *
Personal Information Record for School-Aged Children
Does your child exhibit aggressive behavior? Please describe: *
Has your child ever injured another child or adult? Please describe: *
Please describe any triggers (sounds, smells, actions) if known: *
What does your child usually prefer to do after arriving home from school or on weekends? *
What is your child's favorite snacks? *
Does your child have a strong dislike for certain foods? *
If so, what?
Are there any foods your child is not permitted to eat? *
Are there any activities that you DO NOT want your child to participate in? *
If so, please explain:
Authorization to Leave the Premises
I, (name of parent/guardian) permit my child Encouraging Kids Family Resource Center Respite Programs on predesignated dates as indicated on Respite Calendar(s) for the following purposes:

Field Trips/Outings Walks Other outdoor activities In case of an emergency
I permit my child to leave the premises *

Yes No
Permission to Use Sunscreen
My child, before going outside on warm, sunny days. I, (name of parent/guardian) will provide sunscreen with a sun protection factor (SPF) of 15 or more; without Paba as per EKFRC’s recommendation. Paba gives some children blotchy rashes. I will also make my child’s name of his/her sunscreen PLASTIC container with a permanent marker and keep it in my child’s bag at the facility.
I permit my child to have sunscreen applied *

Yes No
Sick Child Policy
*New protocols are in place to screen for signs or symptoms of COVID-19. These include screening all adults and children for fever prior to entering the premises, questions regarding exposure, etc. All staff wear protective equipment (masks, face shields, gloves) while on the premises. Disinfecting processes ongoing throughout the day and deep cleaning every evening.

We understand the need for parents to have safe, regular, reliable care for their children. We also know how difficult it may be to stay home with a sick child; especially when parents are working full-time. to maintain a safe, healthy, nurturing environment for everyone.

Our priority here at Encouraging Kids is is to keep everyone safe and healthy. To do this we must insist that you keep your child home if he/she has ANY of the following:
- Fever, irritability, lethargy, persistent crying, or difficulty breathing - can be signs of illness.
- An upper respiratory illness , such as bronchiolitis or influenza.
- The common cold with coughing, sneezing, runny nose.
- Diarrhea, Vomiting, Bloody stools or stools containing mucus. These could be the sign of a viral or bacterial infection. (Give your doctor a call!)
- Rash. This is reason to keep your child home unless you know for sure that it's not linked to an infection (for example, if you know it's a reaction to eating strawberries).
- Chicken pox. Child is no longer contagious once all the sores have dried and crusted over.
- Impetigo. Kids with this skin disease are no longer contagious after 24 hours of antibiotics.
- Scabies. Once treated with a topical insecticide, it's no longer contagious.
- Bacterial conjunctivitis (pinkeye) and yellow discharge from the eye.
- Strep throat. It's usually not contagious after 24 hours of antibiotics.
- Mouth sores that cause excessive drooling. Wait until your doctor says they're not infectious
- Head lice. Your child can return after he or she has been thoroughly treated.
- Any other contagious diseases or illnesses not listed above.
*Program supervisors are responsible for deciding whether children are too ill to remain at our programs.

If you are contacted to pick up your child; we expect you to be there as soon as possible. If we cannot reach you; we expect someone else on your child’s emergency contact list will pick your child up. If your child is not picked up within 60 minutes of our call we must, as mandatory reporters, contact DCP&P (formerly DYFS) to have them pick up your child until you can be reached. We can all work together to keep our children as healthy as possible.
I have read and agree to abide by the above sick child policy *

Yes No
After submitting this form and mandatory NJ Department of Children & Families / Dept of Health you will be contacted by our staff for a virtual intake with one of our staff members.
Should be Empty:

Encouraging Kids Family Resource Center

Emergency Contacts:

Family Information

Medical Declaration Statement for School-Aged Care

**IMMUNIZATION RECORD MUST BE SUBMITTED WITH APPLICATION – NO EXCEPTIONS

Personal Information Record for School-Aged Children

Authorization to Leave the Premises

Permission to Use Sunscreen

Sick Child Policy

After submitting this form and mandatory NJ Department of Children & Families / Dept of Health you will be contacted by our staff for a virtual intake with one of our staff members.