Georgia Pre-K 2024/2025 School Year

PROVIDER LEGAL NAME
SCHOOL/SITE NAME
Child Information
Name

CHILD'S FIRST NAMECHILD'S LAST NAME
CHILD'S MIDDLE NAME
NAME SUFFIX
CHILD'S SOCIAL SECURITY#
D.O.B. (MM/DD/BY)

MonthDayYear
Date
Gender

MaleFemale
Address

HOME ADDRESS (Do not enter PO Box Info)

Street Address Line 2

CityState / Province

Postal / Zip CodeCOUNTY
CITY
STATE
ZIP
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
FIRST
MIDDLE INITIAL
Home Address (If different from child)
City
State
Zip
Home Phone
Cell Phone: ( )
Email Address
example@example.com
Work Phone
Address
Place of Employment
City
State
Zip
Parent/Guardian #2 LAST NAME
FIRST
MIDDLE INITIAL
Home Address (If different from child)
City
State
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)
Name

First NameLast Name
Relationship
Cell Phone Number
Please enter a valid phone number.
Alternate Phone Number
Please enter a valid phone number.
Email
example@example.com
I verify the above information to be correct, and I understand that completion of this form does not guarantee placement in a Pre-K class. If my child is placed in Georgia's Pre-K Program, I agree that my child will attend the program for the required number of hours and days as 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

Child Maintenance
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:

	Name	Address	Relationship	Cellphone
1
2
3
4

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

MonthDayYear
Date
Phone Number
Please enter a valid phone number.
MY CHILD HAS THE FOLLOWING SPECIAL NEED(S)
THE FOLLOWING SPECIAL ACCOMMODATION(S) MAY BE REQUIRED TO MOST EFFECTIVELY MEET MY CHILD'S 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

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)

Clear
DATE

MonthDayYear
Date
PHOTOGRAPH/VIDEOTAPE RELEASE

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
, by 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.
This release shall remain binding upon all successors in interest and personal representatives of the
parties, to the extent permitted by law.
PRE K PROVIDER NAME/ADDRESS
SIGNATURE (Parent/Guardian)

Clear
DATE

MonthDayYear
Date
KIDazzle Child Care & Learning Center
1.KIDazzle Child Care & Learning Center agrees to provide child care for the child listed below, beginning Date (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)
2. I 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: Type a label Program Pay: Type a label Sponsor Pay: Type a label Reg Fee: $60.00

I understand that I am responsible for $ Type a label per week.
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):

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 child 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
Facility Administrator Signature

Clear
Date

MonthDayYear
Date
Provider Name (KIDazzle )
Should be Empty:

Child Information

PARENT/GUARDIAN INFORMATION

Child Maintenance

CHILD INFORMATION:

PARENT/GUARDIAN INFORMATION:

KIDazzle Child Care & Learning Center