KIDS SMART, INC

KIDS SMART, INC

REGISTRATION FORM
Childs Name

First NameLast Name
Date of Birth/Age:
Grade:
Attending School:
Teacher:
First date of Attendance:
Home Phone:
Childs Home Address

Street Address

Apartment #

CityState / Province

Postal / Zip Code
Child Identification/PhotoThe attached photo will be used solely for administrative and emergency identification purposes.
Child's Primary Caregiver:
Primary Caregiver Name

First NameLast Name
Caregivers Primary Language
Relationship to child:
Home Address:

Home Address

Apartment Number (if applicable)

CityState / Province

Postal / Zip Code
Home Number
Please enter a valid phone number.Format: (000) 000-0000.
Cell Number
Please enter a valid phone number.Format: (000) 000-0000.
Office Phone:
Format: (000) 000-0000.
Caregiver Employer:
Business Address:
Email Address:
example@example.com
Child's Primary Caregiver 2:
Name

First NameLast Name
Relationship to child:
Home Address:

Street Address

Apartment Number

CityState / Province

Postal / Zip Code
Home Number
Please enter a valid phone number.Format: (000) 000-0000.
Cell Number
Please enter a valid phone number.Format: (000) 000-0000.
Office Phone:
Format: (000) 000-0000.
Caregiver Employer:
Business Address:
Email Address:
example@example.com
Preferred method of emergency contact:
Persons Authorized (other than the above listed caregivers) to pick-up child:
1. Name/Relationship:
Phone:
Format: (000) 000-0000.
Address:
2. Name & Relationship
Phone:
Format: (000) 000-0000.
Address:
3. Name & Relationship
Phone:
Format: (000) 000-0000.
Address:
Child's Primary Physician:
Address:
Phone:
Format: (000) 000-0000.
Dentist:
Address:
Phone:
Format: (000) 000-0000.
Primary Health Insurance:
Policy #:
Preferred Hospital:
Address:
Phone:
Format: (000) 000-0000.
Child's Medical Information:
State-required immunizations?
*provide a copy of these records with enrollment
Please fill out below with applicable information or N/A:
Allergies/Special Diets:
Chronic Medical Problems:
Any Current Medications:
Any Special Needs the program needs to be aware of:
Have you attended Kids SmART before?
Tuition Rate?

PARENT/GUARDIAN AUTHORIZATIONS
Please read the following and sign, stating that you have read and understand the statement. Please also sign your full name at the bottom of the page.
1. Emergency Procedure: In case of an emergency, I authorize the program staff to contact the persons listed on the emergency contact form. I also authorize the physician listed on the other side of this form to provide the necessary medical treatment. If the emergency contact persons cannot be reached, the program's employees are authorized to take necessary action for the health and welfare of my child.
2. Parent Handbook I have received, read, understand and agree to all aspects of the Kids SmART, Inc. Parent Handbook including the liability release. I understand that it is my responsibility as a parent/guardian, to abide by all of the policies and procedures within the parent handbook and any additional addendums provided to me. I understand that those policies and procedures are subject to change, and I will be notified of those changes that are significant and may affect the care of my child. I further understand and agree that, upon repeat notice for failure to comply with the policies and procedures, my family may be excused from the program and be required to find alternative care for my child.
3. Sign in/out Procedure and Responsibility. I agree to abide by the sign in/out procedures as stated in the parent handbook. I understand that the program is not responsible for my child prior to being appropriately signed in. I also understand that the program is not responsible for my child en route to his or her home or authorized destination after he/she is appropriately signed out.
4. Student Records: I agree to keep my child's enrollment and emergency forms up to date, including but not limited to current home and work phone numbers and current phone numbers of those authorized to pick my child up.
5. Potty Training: I confirm that my child is potty trained *All children must be potty trained to attend our programs
6. Payment Policy: I agree to abide by the payment policies as set by Kids SmART, Inc. and will pay the proper dues IN ADVANCE of care. I understand that parent fees are due by the 1st of the month if I am on CCAP, and that out of pocket fees are due prior to care. I understand that if I do not pay and accrue a balance of $100, my child will not be allowed to attend Kids SmART until the balance is paid. Any delinquent balances may be sent to collections with the addition of late fees.
7. Kids SmART, Inc. Activities: I authorize my child to participate in all arts/crafts, science, cooking, gym games, outside games, homework club, planned field trips, etc. organized by Kids SmART staff. Those I do not wish my child to participate in are listed below:
List of non participation activities
8. Television and Movie Consent: Television and movies will be age appropriate, G or PG rating, and viewed on a minimal basis and only with parental consent.
9. Photo/Video Consent: Kids SmART may occasionally photograph or video your child during program hours. These photos or videos may be available for public viewing or used for promotional or advertising purposes. I understand that while in Kids SmART, my child's photo or video may be taken while participating in an activity. Kids SmART will not provide financial compensation for these photos or videos, and I understand that this releases Kids SmART, Inc. from any future claims as well as any liability arising from the use of said photograph or video
10. Transportation of Children: I give permission for my child to participate in field trips where he/she may be transported in approved vehicles away from the program location. I understand that I will be informed in advance of all program field trips.
11. Sunscreen Consent Kids SmART, Inc. on occasion may find it necessary to assist or apply sunscreen to your child. Each child is required to bring their own sunscreen, with an SPF of at least 30, and labeled in it's original container. The program may provide Sunscreen of at least an SPF of 30, for those who have forgotten theirs. I understand that if I do not provide sunscreen my child may be denied activity or asked to be picked up.
Specific Instructions:
Parent/Guardian Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

EMERGENCY / MEDICAL INFORMATION
List at least 3 Persons, other than the caregivers, to contact in the event of an emergency. They will be contacted in the order they are listed.
1) Persons Name:
Relationship:
Home Phone:
Format: (000) 000-0000.
Cell Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Office Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Address:
Specific Instructions:
2) Persons Name:
Relationship:
Home Phone:
Format: (000) 000-0000.
Cell Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Office Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Address:
Specific Instructions:
3) Persons Name:
Relationship:
Home Phone:
Format: (000) 000-0000.
Cell Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Office Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Address:
Specific Instructions:
MEDICAL RELEASE:
Physician Name:
Phone:
Format: (000) 000-0000.
I give permission to Kids SmART, Inc. to take any necessary action for the health and welfare of my child during any emergency situation. This may include contacting the local emergency units prior to contacting the child's physician or parent/guardian. In cases of a medical emergency, I understand that my child will be transported to the closest medical facility by the local emergency unit for medical treatment if the local emergency unit deems it necessary.
EMERGENCY MEDICAL INFORMATION (answer N/A if none):
Allergies/Special Medical Needs
Chronic Medical Problems
Current Medications
Insurance Coverage
Please upload any medical/immunization documentations.

Cancelof
Parent/Guardian Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

KIDS SMART, INC

Child's Primary Caregiver:

Child's Primary Caregiver 2:

Persons Authorized (other than the above listed caregivers) to pick-up child:

Child's Medical Information:

PARENT/GUARDIAN AUTHORIZATIONS

EMERGENCY / MEDICAL INFORMATION

List at least 3 Persons, other than the caregivers, to contact in the event of an emergency. They will be contacted in the order they are listed.

MEDICAL RELEASE:

EMERGENCY MEDICAL INFORMATION (answer N/A if none):