KIDS SMART, INC REGISTRATION FORM

KIDS SMART, INC REGISTRATION FORM
Parent/Guardian Primary Language
CHILD GENERAL INFORMATION
Name:*

Childs First NameChilds Last Name
Date of Birth:*

MonthDayYear
Date
Grade Level:*
Attending School:*
Teacher:
First date of Attendance:*

MonthDayYear
Date
Has your child ever attended Kids SmART before?*
Childs Home Phone:*
Childs Primary Address:*
City:*
State:*
Zip Code:*

PRIMARY CAREGIVER INFORMATION
Childs Primary Caregiver First & Last Name:*
Relationship to child:*
Address:*

Home Address

Street Address Line 2

CityState

Zip Code
Home Phone *
Please enter a valid phone number.
Cell Phone:*
Please enter a valid phone number.
Email Address required:*
example@example.com
Caregiver Employer:
Phone Number
Please enter a valid phone number.
Business Address:

Business Address

Street Address Line 2

CityState

Zip Code
Specific / Special instructions for contacting caregivers:
Are you currently a CDHS - CCAP Client?*

SECONDARY CAREGIVER INFORMATION

if applicable
Childs Primary Caregiver First & Last Name:
Relationship to child:
Address:

Home Address

Street Address Line 2

CityState

Zip Code
Home Phone:
Please enter a valid phone number.
Cell: Phone:
Please enter a valid phone number.
Email Address required:
example@example.com
Caregiver Employer:
Office Phone:
Please enter a valid phone number.
Business Address:

Business Address

Street Address Line 2

CityState

Zip Code
Specific / Special instructions for contacting secondary caregivers:

PERSONS AUTHORIZED TO PICK UP CHILD

Other than the 2 caretakers, please list up-to 3 persons who have authorization to pick up your child. VALID IDENTIFICATION CARD OR LICENSE WILL BE REQUIRED AT TIME OF PICK UP.
1) Authorized Pick-up Person Name:
Relationship to child:
Phone:
Address:

Address

Street Address Line 2

CityState

Zip Code
2) Authorized Pick-up Persons Name:
Relationship to child:
Phone:
Address:

Address

Street Address Line 2

CityState

Zip Code
3) Authorized Pick-up Persons Name:
Relationship to child:
Phone:
Address:

Address

Street Address Line 2

CityState

Zip Code

CHILDS MEDICAL AND CARE INFORMATION
Does your child have state required immunizations?: A copy of these records or exemption form must be provided for enrollment. *
Please list any allergies or dietary restrictions your child may have (or write N/A for none):*
Please list any chronic medical conditions you child may have (or write N/A for none):*
Please list any current medications and/or medications that will need to be administered by Kids SmART. (Epi-pens, inhalers, seizure medications; controlled medications, etc.) or write N/A if none:*
Any Special Needs the program needs to be aware of: (This can include IEPs, BIPs, court orders, On-site therapy/social services visits, child transporation service, etc.)*
Childs Primary Physician:
Phone:
Address:

Business Address

Street Address Line 2

CityState

Zip Code
Childs Dentist:
Phone:
Address:

Business Address

Street Address Line 2

CityState

Zip Code
Primary Health Insurance Provider:
Policy:
Preferred Hospital:
Hospital Phone:
Hospital Address:

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) Authorized Persons Name:*
Relationship to child:*
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Specific / Special instructions:
2) Authorized Persons Name:
2) Relationship to child:
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Specific / Special Instructions:
3. Authorized Persons Name:
3. Relationship to child:
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Specific / Special Instructions:
MEDICAL RELEASE:

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 (or write N/A if none):
Signature*

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Date*

MonthDayYear
Date

ADDITIONAL REGISTRATION DOCUMENTATION

The following documentation can be downloaded (highlighted text below) and completed by your healthcare provider. At the end of this section you will be given an opportunity to upload any documents needed. If your unable to do so now, you can download/print and email them to admin@kids-smart.com
All documentations must be updated/provided yearly. Children will not be accepted into our programs until the following documentation is received:

1) All registrations must include: State approved Immunization Records or Exemption Form.

2) A Child Health Statement form for those who are attending: Eiber Elementary, Compass Montessori, Rocky Mountain Prep Berkeley / Fletcher / Southwest / Ruby Hill

3) All children needing on-site medications will need a Medication Release Form and medications stored in its original container.

4) If your child needs emergency medications, a care plan is also required:

Asthma Health Care Plan

Epi-Pen Health Care Plan

Seizure Health Care Plan
Document Upload

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PARENT / GUARDIAN AUTHORIZATIONS

Please read the following and sign/date stating that you have read and understand the statements.
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.
Signature*

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Date*

MonthDayYear
Date
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.

KIDS SMART, INC SCHOOL AGED PARENT HANDBOOK

KIDS SMART, INC ECE PARENT HANDBOOK
Signature*

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Date

MonthDayYear
Date
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 enroute to his or her home or authorized destination after he/she is appropriately signed out.
Signature*

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Date

MonthDayYear
Date
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.
Signature*

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Date*

MonthDayYear
Date
5. 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. 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 ifI 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.
Signature*

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Date*

MonthDayYear
Date
6. 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 above
Signature*

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Date*

MonthDayYear
Date
7. Television and Movie Consent: Television and movies will be age appropriate and viewed on a minimal basis and only with parental consent.
Approved Ratings for Viewing:*
Signature*

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Date

MonthDayYear
Date
8. 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.
Permission to photograph or video child?*
Signature*

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Date*

MonthDayYear
Date
9. 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.
Signature*

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Date*

MonthDayYear
Date
10. 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.
Permission for Kids SmART, Inc. to apply sunscreen to my child? *
If so specific Instructions
Signature*

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Date*

MonthDayYear
Date
SIGN AND DATE BELOW THAT YOU HAVE READ AND UNDERSTOOD THE ABOVE PARENT/GUARDIAN AUTHORIZATIONS:
Signature*

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Date*

MonthDayYear
Date
Should be Empty:

KIDS SMART, INC REGISTRATION FORM

CHILD GENERAL INFORMATION

PRIMARY CAREGIVER INFORMATION

SECONDARY CAREGIVER INFORMATION

PERSONS AUTHORIZED TO PICK UP CHILD

CHILDS MEDICAL AND CARE 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.

ADDITIONAL REGISTRATION DOCUMENTATION

PARENT / GUARDIAN AUTHORIZATIONS