GA Lottery Pre-k Program : KIDazzle Child Care 2022

School Year
BRIGHT FROM THE START

GA LOTTERY PRE-K P[ROGARM
Pre-K Registration Form
School Year
Georgia Department of Early Care and Learning
PROVIDER LEGAL NAME
(This section to be completed by the provider)
SCHOOL/SITE NAME
(Please print name exactly as it appears on the birth certificate
Parent Name

CHILD'S FIRST NAMECHILD'S LAST NAME
CHILD'S MIDDLE NAME
NAME SUFFIX
CHILD'S SOCIAL SECURITY#
Date of Birth (MM-DD-YY)

MonthDayYear
Date
Sex of the child

FemaleMale
Address

HOME ADDRESS (Do not enter PO Box Info)

Street Address Line 2

CityState / Province

Postal / Zip CodeCOUNTY
CITY
HOME PHONE: ( )
If the Student is transferring from another Pre-K, please provide the following:
Previous School Name
Last Date in Attendance

MonthDayYear
Date
PARENT/GUARDIAN INFORMATION
Parent/Guardian #1 - LAST NAME:
Name

First NameLast Name
Middle Initial:
Home Address (If different from child)
City
State
Zip
Home Phone
Cell Phone
Email Address
example@example.com
Type a question
Work Phone
Address
City
State
Zip
LAST Name
FIRST
Middle Initial
City
Home Address (If different from child)
Zip
Home Phone
Cell Phone
Email Address
example@example.com
Place of Employment
Work phone
Address
City
State
Zip
EMERGENCY CONTACT INFORMATION (Persons to contact in the event that either parent/guardian cannot be contacted)
RELATIONSHIP
EMERGENCY CONTACT 1
Relationship to child
Phone Number

Area CodePhone Number
Alternative Phone
EMAIL

Area CodePhone Number
EMERGENCY CONTACT 2
Relationship to child
Phone Number

Area CodePhone Number
Alternate Phone
Email
example@example.com
Iverifythe above information to be correct, and I understand that completion of this form does not guarantee placement in a Pre-K class. If childplaced in Georgia's Pre-K Program, I agree that my child will attend the program for the required number of hours and days as is my prescribed by the Georgia Department of Early Care and Learning and outlined by the center where my child is enrolled. I understand that failure to comply with these attendance requirements could result in disenrollment. I understand that I cannot register my child without appropriate age documentation. I have attached a copy of appropriate age documentation to this registration form.
Signature Parent/Guardian

Clear
DATE

MonthDayYear
Date

The agree to provide child care for Child's Name on , beginning at 8:00 and ending at 2:30 from August to May .
The agree to provide child care for Child's Name on , beginning at 8:00 and ending at 2:30 from August to May .
CHILD'S LIVING ARRANGEMENTS

BOTH PARENTSMOTHERFATHEROTHER
CHILD'S LEGAL GUARDIAN

BOTH PARENTSMOTHERFATHEROTHER
THE CHILD MAY BE RELEASED TO THE PERSON(S) SIGNING THIS AGREEMENT OR TO THE FOLLOWING: RELATIONSHIP CELL PHONE NAMEADDRESS
Full Name
Address
Relationship
Phone Number

Area CodePhone Number
Full Name
Address
Relationship
Phone Number

Area CodePhone Number
Full Name
Address
Relationship
Phone Number

Area CodePhone Number
Full Name
Address
Relationship
Phone Number

Area CodePhone Number
CHILD'S PHYSICIAN OR CLINIC'S NAME (CHILD'S PRIMARY HEALTH SOURCE): DATE OF LAST FULL HEALTH SCREENING:
DATE OF LAST FULL HEALTH SCREENING

MonthDayYear
Date
PHONE: ( )
MY CHILD HAS THE FOLLOWING SPECIAL NEED(S)
THE FOLLOWING SPECIAL ACCOMMODATION(S) MAY BE REQUIRED TO MOST EFFECTIVELY MEET MY NEEDS WHILE AT THIS CENTER
MY CHILD IS CURRENTLY ON MEDICATION(S) PRESCRIBED FOR LONG TERM CONTINUOUS USE AND/OR HAS THE FOLLOWING PRE EXISTING ALLERGIES, ILLNESS, OR HEALTH CONCERNS

General Release
I verify the above information to be correct and true. I hereby grant permission for the information provided in the preceding Registration Form to be distributed to Pre-K providers, the Department of Early Care and Learning (DECAL), and certain agencies or those entities contracted by Pre-K providers or DECAL which shall include, but not be limited to, the Georgia Department of Education, and colleges/universities. SIGNATURE (Parent/Guardian):
Signature

Clear
DATE

MonthDayYear
Date
I hereby grant permission for the Pre-K provider specified below, the Georgia Department of Early Care and Learning (DECAL) and certain agencies or entities contracted by the Pre-K provider or DECAL which shall include, but not be limited to, the Georgia Department of Education, and colleges/universities, to record the participation and appearance of my child First Name Last Name photograph and/or videotape in connection with daily Pre-K activities for the purposes of news releases, reporting, and assessing the progress of children and the program. DECAL and its contractors are authorized to exhibit or distribute such photograph(s) and/or videotape in whole or in part without restrictions or limitations for any educational or promotional purpose that DECAL deems appropriate. Such photograph(s) and/or videotape may, for example, appear in printed or visual materials for DECAL and/or on DECAL’s web site. The undersigned hereby jointly and severally releases, acquits, forgives, and discharges the Pre-K provider, DECAL, and other entities contracted by the Pre-K provider or DECAL, from any actions, agreements, claims, controversies, demands, judgments, liabilities, proceedings, and suits, whether arising in equity or in law regarding such participation and appearance by said child.
PRE K PROVIDER NAME/ADDRESS
SIGNATURE (Parent/Guardian)

Clear
DATE

MonthDayYear
Date

Parental Agreement with Child Care Facility
The agree to provide child care for Child's Name on , beginning at 8:00 and ending at 2:30 from August to May .
(Month)
(Month)
My child participate in the following meal plan (check applicable meals and sancks)

Type option 1Morning snackLunchAfternoon SnackEvening SnackDinnerBedtime Snack
Before any medication is dispensed to my child, I will provide a written authorization, which includes: Date, Name of Child, Name of Medication, Prescription Number (if any), Dosages, and Date and Time of Day to be given to child. Medicine will be in the original container with my child's name marked on

My child will not be allowed to enter or leave the facility without being escorted by the parent(s) person(s) authorized by parent(s or facility personnel.

I acknowledge it is my responsibility to keep my child's records current to reflect any significant changes as they occur, e.g., telephone numbers, work location, emergency contacts, child's physician, child's health status, infant feeding plans, and immunization records, etc.

The facility agrees to keep me informed of any incidents, including illnesses, injuries, adverse reactions to medications, etc., which include my child.

{name} agrees to obtain written authorization from me before my child participates in routine transportation, field trips,

special activities away from the facility, and water-related activities occurring in water that is more than two (2) feet deep.

I authorize the child care facility to obtain emergency medical care for my child when I'm not

I have received a copy and agree to abide by the policies and procedures for the above-named facility.
Parent/Guardian
Signature

Clear
Date

MonthDayYear
Date
SIGNED

Clear
Date

MonthDayYear
Date
Facility Administrator / Authorized Person

YMCA OF METRO ATLANTA
EARLY LEARNING
Parental Agreements with Child Care Facility
(Name of Facility)
agree to provide child care for
(Name of Child)
(Days of Week)
PM from. (Month) (Month) My child will participate in the following meal plan (circle applicable meals and snacks):
Month to Month

Month Month
(Month)
(Month)
My child participate in the following meal plan (check applicable meals and sancks)

Type option 1Morning snackLunchAfternoon SnackEvening SnackDinnerBedtime Snack
Before any medication is dispensed to my child, I will provide written authorization, which includes: Date, Name of Child, Name of Medication, Prescription Number (if any), Dosages, Date and Time of Day to be given to child. Medicine will be in the original container with my child's name marked on it. My child will not be allowed to enter or leave the facility without being escorted by the parent(s), person(s) authorized by parent(s), or facility personnel. Iacknowledge it is my responsibility to keep my child's records current to reflect any significant changes as they occur, e.g., telephone numbers, work location, emergency contacts, child's physician, child's health status, infant feeding plans, and immunization records, etc. The facility agrees to keep me informed of any incidents, including illnesses, injuries, adverse reactions to medications, etc., which include my child.

agrees to obtain written authorization (Name of Facility) from me before my child participates in routine transportation, field trips, special activities away from the facility, and water-related activities occurring in water that is more than two (2) feet deep.
(Name of Facility)
I authorize the child care facility to obtain emergency medical care for my child when I'm not available.

I have received a copy and agree to abide by the policies and procedures for the above- named facility.
SIGNED:
SIGNED:
Signature

Clear

KIDazzle Child Care& Learning Center
KIDazzle Child Care & Learning Center

1.KIDazzle Child Care & Learning Center agrees to provide child care for the child listed below, beginning (date) and continuing until written notification is provided by either party. The operating hours are 6:30 am 6:00 pm, Monday - Friday.
(Child's Name)
(Child's Name) 2. ! agree to pay all tuition fees per week for as long as the child is enrolled in the program. A two week notice must be given for withdrawal. I understand that no deduction will be made for holidays, inclement weather, or other times child is not in attendance at the center. A vacation credit is given for each six months the child is enrolled. I also understand that the center closes at 6:00 PM. I will be charged a late fee of $2.00 per minute, payable before my child returns the following day. Pre-K Only - I understand that there is no charge for tuition during the funded 6.5 hours of the instructional Pre-K day, 8:00 AM - 2:30 PM. A fee will be charged for Before and After Care for children in attendance outside the Pre-K hours.

(Tuition Fees:) Program: Total Weekly Tuition:
Program
Total Weekly Tuition
Sponsor Pay
I understand that I am responsible for $
3. If a portion of the tuition is subsidized by another agency, I agree to provide all necessary paperwork and information in a timely manner. 4. My child will participate in the following meal plan (circle applicable meals and snacks): Breakfast Lunch Afternoon Snack Dinner (school age only) 5. I understand that KIDazzle does not dispense medication. Special permission must be given for any medication to be kept on site or dispensed (Epi Pen, Asthma treatment, Skin medication If medication is kept on site I will provide a written authorization which includes: date, name of child; name of medication; prescription number; dosage; date and time of medication to be given. Medicine must be in the original container with child's name on it.

6. My child will not be allowed to enter or leave the facility without being escorted by the parent(s), persons authorized by parents, or facility personnel. Child must be checked in/out on the computer daily and must be taken to their assigned classroom and placed in teachers care. 7. I acknowledge that I have been given a copy of the Safe Sleep Policy and a signed copy will be retained in my child's file. 8. I acknowledge it is my responsibility to keep my child's records current to reflect any significant changes as they occur, for example; telephone numbers, work locations, emergency contacts, child's physician, child's health status, and immunization records.

9. The facility agrees to keep me informed of any incidents including illnesses, injuries, adverse reactions to medicines, etc. which include my child. I authorize KIDazzle to obtain emergency medical care for my child if I am unavailable and the center deems necessary.
10. KIDazzle Child Care & Learning Center agrees to obtain written authorization from me before my child participates in routine walking or transportation, field trips, special activities away from the facility, and water related activities occurring in water that Is more than two (2) feet deep.
11. I grant permission for my child to be included in evaluations and pictures connected with the school program.

12. I will not bring my child to the center with signs/symptoms of illness (Fever, rashes, pink eye, diarrhea, etc ) and agree to pick up, or arrange for the chlld to be picked up immediately if he/she becomes sick at the center. 13. A copy of the Parent Handbook, which contains the Health and Discipline policies, is available on the KIDazzle website. I have been informed that if I cannot print a copy from the website a copy will be provided to me. I agree to abide by the policies and procedures for KIDazzle Child Care & Learning Center.
14. I understand that KIDazzle will advise me of my child's progress and issues relating to my child's care as well as any individual practices concerning my child's special needs. I also understand that my participation is strongly encouraged in facility activities.
Parent/Guardian Signature

Clear
Date

MonthDayYear
Date

BRIGHT FROM THE START

Pre-K Registration Form

School Year

PARENT/GUARDIAN INFORMATION

RELATIONSHIP

THE CHILD MAY BE RELEASED TO THE PERSON(S) SIGNING THIS AGREEMENT OR TO THE FOLLOWING: RELATIONSHIP CELL PHONE NAMEADDRESS

CHILD'S PHYSICIAN OR CLINIC'S NAME (CHILD'S PRIMARY HEALTH SOURCE): DATE OF LAST FULL HEALTH SCREENING:

General Release

Parental Agreement with Child Care Facility

YMCA OF METRO ATLANTA

EARLY LEARNING

SIGNED:

SIGNED:

KIDazzle Child Care& Learning Center

10. KIDazzle Child Care & Learning Center agrees to obtain written authorization from me before my child participates in routine walking or transportation, field trips, special activities away from the facility, and water related activities occurring in water that Is more than two (2) feet deep.

14. I understand that KIDazzle will advise me of my child's progress and issues relating to my child's care as well as any individual practices concerning my child's special needs. I also understand that my participation is strongly encouraged in facility activities.

BRIGHT FROM THE STATE: ROSTER INFORMATION

HEAD START ATTENDANCE POLICY

If the school has not heard from you by 9am, calls will be made, starting wit you and contacts if needed. Then if we cannot get anyone on the phone a home visit will take place.