• CHILD ENROLLMENT AND HEALTH INFORMATION FOR CHILD CARE

    • Child Information 
    •  / /
    • Format: (000) 000-0000.
    • Parent/Guardian Information 
    • Format: (000) 000-0000.
    • Format: (000) 000-0000.
    • Format: (000) 000-0000.
    • Please indicate if this name should be released if a parent/guardian of a child attending the program requests contact information for other parent/guardians.
    • If you answered yes, please indicate which information above to include on the list
    • Format: (000) 000-0000.
    • Format: (000) 000-0000.
    • Format: (000) 000-0000.
    • Please indicate if this name should be released if a parent/guardian of a child attending the program requests contact information for other parent/guardians.
    • If you answered yes, please indicate which information above to include on the list
    • Emergency Contact Information 

    • Emergency Contacts: Parents cannot be listed as emergency contacts. List the name of at least one person who can be contacted in the event of an emergency or illness if you cannot be reached. Any person listed should be able to assist in contacting you. At least one person listed must be able to take responsibility for the child in case the parent/guardian cannot be contacted and should be at least 18 years of age.

    • Format: (000) 000-0000.
    • Format: (000) 000-0000.
    • Format: (000) 000-0000.
    • Format: (000) 000-0000.
    • Preferred Physician or Clinic/Hospital 
    • Format: (000) 000-0000.
    • Allergies, Special Health or Medical Conditions, and Medical Foods 

    • Allergies, Special Health or Medical Conditions, and Medical Foods

      Fill in this section accurately and completely. Please note that if your child has a current health or medical condition requiring child care staff to perform child specific care, such as: to monitor the condition, provide treatment, care, or to give medication, the JFS 01236 "Child Medical/Physical Care Plan for Child Care" must be completed and be kept on file at the program/home.

    • Does your child have any food, medication or environmental allergies? (check all that apply)
    • Does your child's allergy/allergies require child care staff to monitor your child for symptoms to take action if a reaction occurs, or give emergency medication to your child? (check one):
    • Does your child have a developmental delay or special health or medical condition? (check one):
    • Does the special health or medical condition require child care staff to perform a procedure, or perform child specific care such as: to monitor your child for symptoms or administer medication during child care hours? (check one):
    • Is your child currently using any medication or medical food? (check one):
    • If yes, does this medication or medical food need to be administered at the child care program/home?
    • Does your child have any dietary restrictions, including those for medical, religious or cultural reasons? (check one):
    • Does this dietary restriction require a modified diet that eliminates all types of fluid milk or an entire food group?
    • Additional Child and Household Information 
    • Is your child toilet trained?*
    • The program's policy is to check diapers every 2 hours. Please indicate if you want your child's diaper checked according to the program's policy or another:

    • Please check my child's diaper every hour(s).

    • Emergency Transportation Authorization 
    • Permission to secure emergency transportation.
    •  - -
    •  - -
    • Acknowledgement of Policies and Procedures 
    • I have reviewed and received a copy of the program's or home's policies and procedures/handbook.*
    • Authorized Pickup List 

    • Please use this section to add those individuals to whom you are giving permission to pick up your child from care. Previously listed Parent/Guardian and Emergency contacts are already authorized.

  • Family Needs Survey For Step Up To Quality

    We want to support any needs you or your family may have. THE INFORMATION YOU PROVIDE ON THIS FORM IS CONFIDENTIALPlease choose Y (YES) or N (NO) to best describe your current situation for each topic. If you choose Y for an item, please briefly list the CONCERNIf this is an area of need for your child or family. Our goal is to provide resources to support you and your family, based on your answers.

  • Does any one in your family have any need for resources or support in the areas listed below?

    • Child Development and Education.  
    • Information on child growth and development.
    • Guiding and supporting a child's behavior.
    • Medical or disabilities or possible conditions for any child or adult in the family.
    • Obtaining toys or activities to use to help any child in your home.
    • Preparing your child for kindergarten.
    • Child and Family Health 
    • Health insurance and/or access to regular medical care, dental care, ormedications.
    • Medical or health supplies or supports that anyone in your family needs.
    • Accessing immunizations.
    • Finding a pediatrician, general practitioner, dentist, therapist, psychologist, optometrist, or other specialty practitioner.
    • Concerns with depression, anger, anxiety, or mental health needs.
    • Concerns with alcohol, drug, or addiction problems.
    • Financial and Household Supports 
    • Help paying for child care.
    • Help finding housing or safe housing.
    • Help paying your mortgage or rent.
    • Help with food expenses.
    • Finding household items such as furniture, clothing, or school supplies.
    • Access to transportation or transportation expenses.
    • Attending school (such as a GED, Certifications, or college degrees).
    • Help finding work or job training.

    • Are there other needs you or your family have that are not listed above:

    • Summer Camp 
    • Sunscreen package ($10.00 per child). We will provide SPF 50 sunscreen for the duration of camp.
    • Do You Need:
    • Weeks Attending:
    • Can your child swim?
    • Permissions & Waivers 
    • Permission to apply sunscreen to your child's face, neck, ears, and arms if help is needed:

    • Permission to photograph/video

      Occasionally, Kids Encounter staff takes pictures of the children during normal classroom activities, special occasions, field trips, etc. in order to provide pictured records and memories of these events. In order for a child to have his/her photograph taken, we must have a consent form on file.

      By signing this form, I state that I understand and agree that my child (whose name is listed above) may be photographed and/or videoed while under the care of Kids Encounter. I understand and agree that these photos/videos may be used in newsletters and/or the Kids Encounter website/Facebook.

    • Please check ONE of the following indicating if you do or do not give permission for your child to be photographed and videoed.

    • I give my permission for my child to participate in The Kids Encounter Summer Camp at Encounter and to be involved in any and all activities and field trips scheduled and unscheduled. Scheduled and unscheduled field trips will take place away from the church building but always as a group with proper adult supervision. These activities include but are not limited to: movies, water parks, zoos, factories, parks, stadiums, and museums. These activities may require your son/daughter to be transported on Encounter-owned vehicles. Please complete and sign the following form to serve as the permission slip for all activities and transportation.

      HOLD HARMLESS AGREEMENT

      I understand that participation in the summer camp involves a certain degree of risk. I have carefully considered the risk of involvement and have given consent for my child to participate in all activities. I understand that participation in these activities is entirely voluntary and requires participants to abide by applicable rules and standards of conduct. I release Encounter, Kids Encounter Summer Camp, the activity coordinators, and all employees, volunteers, related parties, and other organizations associated with the summer camp from any and all claims or liability arising out of this participation.

      In case of an emergency involving my child, I understand every effort will be made to contact me. In the event these attempts prove unsuccessful, I hereby give my permission to the medical provider selected by the adult leader in charge to secure, at my expense, proper treatment, including hospitalization, anesthesia, surgery, or injections of medication for my child. Medical providers are authorized to disclose to the adult in charge examination findings, test results, and treatment provided for the purposes of medical evaluation of the participant, follow up and communication with the participant’s parents or guardian, and/or determination of the participant's ability to continue in the program activities.

      By signing this form you assume the entire responsibility and liability for losses, expenses, damages, demands, and claims based on any sustained or alleged to have been sustained by Encounter, its agents, servants, and employees from any and all such losses, expenses, damages, demands and claims.

    •  / /

  • Child and Adult Care Food Program (CACFP)

    Kids Encounter is an equal opportunity provider
    • Child's Schedule 

    • Please select the days normally in care.
    • Meals received while in care.
    • Meals received while in care.
    • Meals received while in care.
    • Meals received while in care.
    • Meals received while in care.
    • Child Ethnic and Racial Data Form 

    • The agency or daycare listed above receives Federal financial assistance for participating in the Child and Adult Care Food Program (CACFP). Because they receive Federal financial assistance they are required to record and maintain the Ethnic and Racial data of all children enrolled in the CACFP. This information is used solely for the purpose of determining compliance with Civil Right laws and will be kept confidential. We are requesting for each participant to ‘Self Identify’ and provide this information, however it is optional to Self Identify. This ethnic and racial information will remain confidential and on file for 3 years and will only be accessible to authorized personnel.

      To Self Identify, please answer the following questions.

    • Ethnicity
    • Racial Categories

    • Household Information

    • Enrolled Children 

    • Please list all children enrolled with center.
    •  - -
    • Foster child?
    • Do you need to add an additional child?
    •  - -
    • Foster child?
    • Do you need to add an additional child?
    •  - -
    • Foster child?
    • Do you need to add an additional child?
    •  - -
    • Foster child?
    • Household Size and Total Gross Income. 
    • Does the household have?

    • List all names of household members including children.
    • Does this person have an income?

    • Please complete all that apply. Please leave blank if zero.
    • Does this person have an income?

    • Please complete all that apply. Please leave blank if zero.
    • Does this person have an income?

    • Please complete all that apply. Please leave blank if zero.
    • Does this person have an income?

    • Please complete all that apply. Please leave blank if zero.
    • Does this person have an income?

    • Please complete all that apply. Please leave blank if zero.
    • Does this person have an income?

    • Please complete all that apply. Please leave blank if zero.

  • Signature

    I certify that all information on this form is true and correct and that all income is reported. I understand that the center will get Federal Funds based on the information. I understand that CACFP officials may verify the information. I understand that if I purposely give false information, I may be prosecuted.
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      Registration

      Registration fee per family

      $30.00
        
      Total
      $0.00

      Payment Methods

      creditcard
      After submitting the form, you will be redirected to Apple Pay to complete the payment.
      After submitting the form, you will be redirected to Google Pay to complete the payment.
      After submitting the form, you will be redirected to Cash App Pay to complete the payment.
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