KRK Enrollment Forms Part 1

ENROLLMENT APPLICATION
Child's Name*

First NameLast Name
Nickname*
Sex*
Date of Birth*

MonthDayYear
Date
Child's Address*

Full Address (Street, City, State/ Province, Postal/ Zip Code)

Street Address Line 2

CityState / Province

Postal / Zip Code
Starting Date*

MonthDayYear
Date
Starting Room #*

Mother's Name*

First NameLast Name
Address*

Street Address

Apt

CityState / Province

Postal / Zip Code
Home Phone:
Please enter a valid phone number.
Work:
Please enter a valid phone number.
Cell:*
Please enter a valid phone number.
Email*
example@example.com
Place of Employment*
Normal Hours:*
Work Address:*
Full Address (Street Address, City, State/ Province, Zip/ Postal Code)

Father's Name*

First NameLast Name
Address*

Street Address

Apt

CityState / Province

Postal / Zip Code
Home Phone:
Please enter a valid phone number.
Work:
Please enter a valid phone number.
Cell:*
Please enter a valid phone number.
Email*
example@example.com
Place of Employment*
Normal Hours:*
Work Address:*
Full Address (Street Address, City, State/ Province, Zip/ Postal Code)

Emergency Contacts

The persons listed below may be contacted in the event of an emergency, AND are also authorized to drop off and pick up this child. List at least 2 names.
Emergency Contact # 1 *

Full Name

Full Address

Phone NumberState / Province

Relationship
Emergency Contact # 2*

Full Name

Full Address

Phone NumberState / Province

Relationship
Emergency Contact # 3 (optional)

Name

Full Address

Phone NumberState / Province

Relationship

Child's Doctor*
Address*
Phone Number*
Please enter a valid phone number.
Childs Allergies, special medical conditions or prescribed drugs:*
I authorize Kids ‘R’ Kids to obtain any and all medical treatment to be performed as deemed necessary by Kids ‘R’ Kids staff, licensed medical personnel, including emergency personnel, ambulance personnel and doctors and nurses. I understand that Kids ‘R’ Kids does not provide accident insurance and further agree to be fully responsible for all medical expenses incurred and to hold harmless and release Kids ‘R’ Kids and Kids ‘R’ Kids Intl from all liability.
Signature

Clear
Date

MonthDayYear
Date
This is to certify that I have read the transportation procedures and give permission for Kids ‘R’ Kids to transport my child for the following:
Emergency Only To and From* Type a label* School.

My child will attend KRK the following days and hours:
Monday Tuesday Wednesday Thursday Friday*
From:blanks* To: blank*.
- I agree to pay the tuition every two weeks in advance each Friday for the upcoming 2 weeks. Late payment fee of $50 will be applied if not paid by Monday end of day of the week due.
- I understand that my child will be provided all snacks and lunch served daily during their hours of attendance. Breakfast is served until 7:30 am. Because of food allergies, outside food is not allowed in the school.
- For infants, I understand I am responsible for any special diet required by my child. I will provide the food and formula daily to the center. All bottles and other containers will be clearly labeled with the Child’s full name and dated.
- I understand that it is my responsibility to escort my child into the center and to the classroom or café and insure the teacher is aware of the child’s arrival or departure.
If my child needs diapers, I will provide whatever disposable diapers are required.*

My child has been potty trained.My child has not been potty trained
- A clean change of clothes for any child up through the pre-k program must be in the classroom at all times. These clothes must have the child’s name on each item.
- Children at the center may be photographed by other parents and are visible to other parents via the internet. Photographs may also be posted within the center or on the school web site. I give my
  permission for my child to be photographed or videotaped while in attendance at the center and during any field trip activities.
- I understand that the center has a specific policy regarding the administration of medicine. I agree to provide the center with all required information in accordance with this policy. Medicines including over the counter, are administered only as prescribed by a licensed physician.
- I understand that if my child is ill, including but not limited to a severe cough, undetermined rash or spots, temperature over 100 degrees, severe headaches, upset stomach, pink eye or diarrhea, he
  or she cannot be accepted into the center until well. In the event my child has a contagious disease, a release form from a medical source may be required before my child re-enters the center.
- If I have not picked up my child by 7pm, and we are unable to contact the parents and other emergency and pickup contacts, Kids ‘R’ Kids will contact Child Protective Services or local police.
- I understand it is my responsibility to keep the center advised on changes of address, phone numbers, and contacts. I will provide a current immunization records prior to enrollment and will
  update as required.
- I give my permission for the child listed on this application to participate in field trips sponsored by this center. I understand I will need to sign a permission slip for each field trip. (older children only)
- I understand that I must give two weeks written notice to the Director prior to the withdrawal of my child. Tuition continues to be due and payable during this period.
- If my child is part of the after school program, I must notify the school no later than 1:30 pm if he/she will not be riding the bus for that day. Failure to notify us will result in delays as we attempt to locate your child and will result in a $15 fee.
SCHOOL AGE CHILDREN: My child attends blanks*. The phone number at the school is blank*. I certify that my child's current immunizations are on file at the school.
I have read all of these policies and understand any changes to information submitted can only be made by the parent(s) that sign below. I have received a copy of the Parent Handbook. I have read and understand the Parent Handbook.
1 - Parent Signature*

Clear
1 - Printed Name*
2 - Parent Signature

Clear
2 - Printed Name
Date*

MonthDayYear
Date

EMERGENCY INFORMATION CARD
Phone Number*
Please enter a valid phone number.
Allergies to medicine:*
Allergies to food:*
Special instructions required in caring for your child:*
Parent/ Guardian Signature

Clear
Date

MonthDayYear
Date

I fully understand that my enrollment fee deposit of $blanks* ensures enrollment of my child(ren) at Kids 'R' Kids of Liberty Field for a proposed start date of blank*. I also understand that the Enrollment Fee Deposit (including 1st Week Tuition + Registration Fee) is NON-REFUNDABLE. The reason the fee is non-refundable is because the school will hold a spot for my child and determine space availability for new enrollees based on my future enrollment.

I understand that if my child has not started attendance at Kids ‘R’ Kids of Liberty Field by the second week AFTER my proposed start date (listed above) and I have made no effort to contact the school, Kids ‘R’ Kids of Liberty Field reserves the right to cancel my enrollment.
Registration Fee $ 100
1st Wk Tuition $Type a label*
Supply Fee $ 80
Enrichment FeeType a label*
Signature*

Clear
Date*

MonthDayYear
Date
A copy of your response will be sent to the email address below:*
example@example.com
Should be Empty:

ENROLLMENT APPLICATION

Emergency Contacts

EMERGENCY INFORMATION CARD