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KPL - Enrollment Form
Family Unique ID
Other Info
Primary Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
What primary language is spoken at home?
*
Spanish
English
Other
Zip Code of Primary Residence
*
County of Primary Residence
*
How did you learn about Kaleidoscope Play & Learn?
*
Word of mouth
Social Media
Referral from Community Partner
Traditional Media (television/radio/newspaper)
Outreach Event
Other
Parent/Guardian/Caregiver Information
To continue offering this activity, we are required to report certain data to the state. Your individual names and contact information will not be shared. Instead, each family will be assigned a unique ID (for example, “Zebra Family”) to ensure your personal information remains confidential. Thank you for your support!
1) Parent/Guardian/Caregiver's Name
*
First Name
Last Name
Parent/Guardian Type
*
Parent
Guardian
Grandparent
Relative
Other
Do you consider yourself Hispanic or Latino?
*
Yes
No
I prefer not to answer this question
Please select your race:
*
American Indian/Alaskan Native
Asian
Black/African American
Multi Racial/Mixed Race
Middle Eastern/North African
Native Hawaiian/Pacific Islander
White
I prefer not to answer this question
Other
2) Parent/Guardian/Caregiver's Name
First Name
Last Name
Parent/Guardian Type
*
Parent
Guardian
Grandparent
Relative
Other
Do you consider yourself Hispanic or Latino?
*
Yes
No
I prefer not to answer this question
Please select your race:
*
American Indian/Alaskan Native
Asian
Black/African American
Multi Racial/Mixed Race
Middle Eastern/North African
Native Hawaiian/Pacific Islander
White
I prefer not to answer this question
Other
3) Parent/Guardian/Caregiver's Name
First Name
Last Name
Parent/Guardian Type
*
Parent
Guardian
Grandparent
Relative
Other
Do you consider yourself Hispanic or Latino?
*
Yes
No
I prefer not to answer this question
Please select your race:
*
American Indian/Alaskan Native
Asian
Black/African American
Multi Racial/Mixed Race
Middle Eastern/North African
Native Hawaiian/Pacific Islander
White
I prefer not to answer this question
Other
Child(ren's) Information
Please list all children in the household (birth to age 5). Please include older siblings if they may attend KPL during holidays, school breaks etc.)
1. Child's Name
*
First Name
Last Name
Child's Date of Birth
*
-
Month
-
Day
Year
Date
Allergies or other concerns:
2. Child's Name
First Name
Last Name
Child's Date of Birth
-
Month
-
Day
Year
Date
Allergies or other concerns:
3. Child's Name
First Name
Last Name
Child's Date of Birth
-
Month
-
Day
Year
Date
Allergies or other concerns:
4. Child's Name
First Name
Last Name
Child's Date of Birth
-
Month
-
Day
Year
Date
Allergies or other concerns:
List additional child(ren) (name and birthdate) if more space is needed.
Emergency Contact
Who should we contact in an emergency?
Emergency Contact Name:
*
First Name
Last Name
Home/Cell Phone:
*
Please enter a valid phone number.
Work Phone:
Please enter a valid phone number.
Does this person have permission to pick up your child in an emergency?
*
Yes
No
Smart Start Rowan - KPL Waivers & Permissions
Kaleidoscope Play & Learn Participation Agreement: (Please select each box to indicate agreement.)
*
I will participate & interact with my child to promote learning though play at home and in group.
I will use handout information and ideas at home as they are relevant to my family.
I will notify the facilitator in advance whenever I am not able to attend.
I will not participate if either myself or anyone in my household is sick which includes having a fever of 100 degrees of higher within the last 24 hours.
I will use positive and appropriate words and actions when correcting my child's behavior and in my interactions with other parents.
I will not share personal information outside of the group.
Parent Responsibilities: I acknowledge and accept that I am responsible for my child/children the whole time I participate in the Kaleidoscope Play and Learn Group. I understand that the playgroup rules will be in effect during the session and that for the safety of my child and other children in the playgroup, the rules and instructions given by the facilitator should be followed at all times.
*
I Understand and Accept
Permission to Use Photograph/Video Footage: I grant Smart Start Rowan, it's representatives and employees, to take, use, and publish photographs and video footage of me and/or my child, both in print and/or electronically. I agree that Smart Start Rowan may use such photograph/video footage of me and/or my child(ren) without names and for any lawful purpose, including such purposes as publicity, illustration, advertising, and Web content.
*
I Understand and Accept
I DO NOT grant permission to use videos/photos of me or more child(ren)
I will hold harmless Smart Start Rowan staff and the site for any accidents or injuries to persons or property or both, arising from participation in Kaleidoscope Play & Learn.
*
I Understand and Accept
Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: