Kidz Club ASP REGISTRATION

Child/Children's name, grades and birthdates

Child 1

Child 2

Child 3

Do any of these children have an IEP?

If yes, please provide a copy of the IEP if and only if you feel comfortable or if you think the information could aid us in homework/behavioral help for your child.

Parent or Legal Guardian

Email

example@example.com

Relationship

Address

Phone Number

Parent or Legal Guardian

Relationship

Address

Phone Number

Emergency Contacts/Authorized to pickup

I authorize Kidz Club ASP to release my child/children to the following people. I understand that my child will not be permitted to leave the ASP with anyone who is not listed unless the ASP receives advance notification from a parent or guardian. Anyone who is unknown to the staff will be asked for picture ID. Parents and guardians listed above are automatically authorized to pick up your child unless the program is given a copy of a current court ordered custody agreement or restraining order.

Name

Address_

Relationship

Phone Number

Name

Relationship

Address

Phone Number

Name

Relationship

Address

Phone Number

Does your child have allergies? If so, please provide a copy of your child's action plan

IF ADDITIONAL ALLERGY PAGES ARE REQUIRED, WE CAN PROVIDE MORE SPACE.

Separate medical forms will be required for any medication that would be needed to be administered at the ASP. Prescription medication (example- EPI pen) require an MD signature. NON-prescription medicine that needs to be administered (example-allergy medicine) requires a parent signature.

What are your child's favorite hobbies, games, books, toys?

How does your child show happiness, anger/disappointment? Only feel you have to share if you think it could help us meet your child's emotional needs. If necessary, what is the most effective way to deal with redirection or behavior?

Is there any additional information you would like us to know about your child?

Support staff: I give permission for the ASP staff to talk with my child's classroom teacher or school personnel should there be a need to work together to better serve my child.

Yes/No

Photographs/Social Media: Kidz Club ASP will have a parents Facebook page to keep parents informed and included in our daily activities. It will be a closed, private page that only guardians listed on the registration will have access to, as well as our staff members. We hope to share events, reminders and photos with parents. Do you give the ASP permission to post your child's photo on this private platform?

Yes/No

Does your child have a physical or emotional condition of which we should be aware? If yes, please send a detailed email or you may choose to have a phone conversation prior to school starting.

Are your child/children's updated records of a physical exam/immunization or file at Saint Josephs?

Yes

Thank you for trusting the Kidz Club ASP with your kiddos! Please email this registration form and your September Calendar to KidzClubASP@gmail.com at your earliest convenience to secure your spot.

Theresa McLennan and Allie Gagne

Parent Guardian Signature

Kidz Club After School Program 2022-2023 Registration/Waivers/Family Information