K.A.R.E.

Child's Information
Child's Name*

First NameLast NameNickname
Child's Date of Birth*

MonthDayYear
Date
Child's School*
Select Your Child's Current Grade Level:*
Parent(s)/Legal Guardian Information
Parent/Legal Guardian 1*

First NameLast Name
Parent/Legal Guardian 2 (optional)

First NameLast Name
Email*
example@example.com
Home Phone*

Area CodePhone Number
Cell Phone*

Area CodePhone Number
Work Phone*

Area CodePhone Number
How will your child ARRIVE to Cape Assist?*
How will your child DEPART from Cape Assist?*
Authorized Pick-up & Emergency Contact Information
Name*

First NameLast Name
Relationship*
Phone Number*

Area CodePhone Number
Name

First NameLast Name
Relationship
Phone Number

Area CodePhone Number
Name

First NameLast Name
Relationship
Phone Number

Area CodePhone Number
Medical Information
Allergies*
Medical Conditions
Please list any special conditions, medications, dietary restrictions, or disabilities.
Family Physician
Phone Number

Area CodePhone Number
Behavior Rules for K.A.R.E. Center After-School Program

Please review the program rules with your child and ensure they understand them.
I understand that to provide a program that is fun and safe that there must be rules. I agree to follow KARE rules and I understand that if I do not, I may be suspended for a day or asked to leave the program.
- I know that I must treat the Cape Assist staff and the other children with respect.
- I know that I am to stay in my seat during crafts, lessons and snack time.
- I know that I may not leave the Cape Assist without permission.
- I know that I must keep my hands and feet to myself .
- I know that I must raise my hand before speaking.
I understand that the Cape Assist staff has decided that following the rules will be the best way to provide a safe and fun experience for all.
Parent/Legal Guardian Consent & Agreement for Medical
As the legal parent/guardian, I give consent to have my child, {name}, to receive first aid by a staff of Cape Assist and if necessary, to be transported to receive emergency care. I also authorize Cape Assist to contact my child’s health care provider to alert him/her of my child’s situation. I understand that I will be responsible for all charges not covered by insurance. I give Cape Assist consent to act on my behalf if the parent/legal guardian and the emergency contacts are not available.
Parent/Legal Guardian Consent & Agreement for Media Release
I, {name10}, agree and consent that my child’s, {name}, name, photo, age/grade, attending school, likeness, appearance, image, voice, video, and artwork may be used for promotional, advertising, and educational material including but not limited to print, digital, direct mail, and for use on the internet for an indefinite duration. I acknowledge that this consent will also cover any virtual sessions conducted through video conferencing such as Zoom or any other video and/or phone conferencing platform that Cape Assist may utilize as part of the program.
Parent/Legal Guardian Consent & Agreement for Trips
I, {name10}, agree and consent that my child, {name}, has permission to walk or be transported to local parks or any other locations for activities under the care and supervision of a Cape Assist staff. I acknowledge that trips within a 1-mile radius from the Cape Assist building location, 3819 New Jersey Avenue, Wildwood, NJ 08260, will not require prior notification. Any trips outside that may occur outside of a 1-mile radius of the Cape Assist headquarters, the legal parent/guardian will be notified 48-hours before the occurrence of the trip. I acknowledge that this consent will be valid for the duration of the program/event and no additional consent for trips will be provided.
By signing below, you agree to the following (unselect what you do not agree to):

Medical ConsentMedia ReleaseField Trip Consent
Legal parent/guardian signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Child's Information

Parent(s)/Legal Guardian Information

Authorized Pick-up & Emergency Contact Information

Medical Information

Behavior Rules for K.A.R.E. Center After-School Program

Parent/Legal Guardian Consent & Agreement for Medical

Parent/Legal Guardian Consent & Agreement for Media Release

Parent/Legal Guardian Consent & Agreement for Trips