Medical Form

SUPER STARS AFTER SCHOOL KIDZ CLUB - ENROLLMENT AND PERMISSION FORMS

Please fill in, upload, and sign all required forms before the first class
Personal Profile Information
Child Information
Name

First NameLast Name
Nickname
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent Information
Parent / Guardian 1 Name

First NameLast Name
Parent / Guardian 1 Email
example@example.com
Parent / Guardian 1 Phone Number
Please enter a valid phone number.
Parent / Guardian 2 Name

First NameLast Name
Parent / Guardian 2 Email
example@example.com
Parent / Guardian 2 Phone Number
Please enter a valid phone number.
Caregiver Information
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
List two additional contacts in case of emergency
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
I affirm that the emergency contacts listed above are authorized to pick up my child and can make medical decisions for my child in case of emergency. Signature of Parent / Guardian (type full name):

First NameLast Name

Child Health Examination Form
We are required to have your child's health exam form on file. You can download the form below and print it out for your doctor to fill out.
Please upload your child's completed CHILD & ADOLESCENT HEALTH EXAMINATION FORM here.

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Authorized Escorts List Form
We are required to have your child's escort list form on file. You can fill in the form below, or you can download and print it out, then upload it.
Please upload your child's completed AUTHORIZD ESCORTS LIST FORM here.

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Super Stars Afterschool Kidz Club Waiver Form
Children enrolled in independent participation classes must be picked up promptly at the end of class. If the adult picking up is more than 15 minutes late and it is not the first occurrence, the Super Stars Kidz Club will charge a $15 late pick-up fee. Should late pick-up continue to occur, additional charges will be made at management’s discretion.

I understand and accept the following:
- It is my sole responsibility to ensure that the SSAKC has the correct and current contact information on file for matters pertaining to the child’s enrollment in any program and for medical and non-medical emergencies, including the signed and updated waiver to be kept on file while participating in any SSAKC program.
- The SSAKC may use any photographs taken of me or my child during classes, camp, etc., for marketing, advertising, and promotional materials, including but not limited to display, distribution, and/or online, unless I opt out in writing with center management.
- The SSAKC Wellness Policy states that children showing any signs of illness, including but not limited to a runny nose, cough, vomiting, diarrhea, or fever, may not participate in programs at the SSAKC.
- The SSAKC is not responsible for any items lost or stolen on the premises of the location.
- The SSAKC reserves the right to cancel or modify classes and programs and/or make changes to instructors and staff.
- I will provide current medical and immunization records for my child prior to participation in programs at the SSAKC.
- I certify that my child has no condition that prohibits safe participation in activities at the SSAKC.
- Adults responsible for the enrolling student realize the risk of injury involved and hereby agree to assume the responsibility of such for themselves and their child, and further agree to hold harmless the SSAKC, its employees, and all others concerned, and to indemnify them against loss and will forever waive my right to sue the SSAKC.
- In case of emergency, if I cannot be reached, I authorize the SSAKC, its agents, and employees to contact and secure necessary medical attention for my child.
- I understand and accept the SSAKC refund policies as listed on the website:
I accept all of the SSAKC terms and conditions outlined above. Parent / Guardian signature (type your full name below)

First NameLast Name
Child's Name

First NameLast Name
Relationship to child
Today's Date

MonthDayYear
Date

Super Stars Afterschool Kidz Club Pick up Policy
Daily Sign In / Sign out

All students must be signed in and out on the daily attendance sheet by their parent/cargiver. Students will only be released to adults indicated as an authorized pick-up individual. All changes and authorization for pick up must be provided in writing by the parents or legal guardian. Staff will verify authorized pick-up individuals with photo ID. Students will not be released to unauthorized individuals nor any individuals appearing to be unwell/intoxicated.

Notificiation of Late Pick-up

If there is something preventing a child from being picked up on time, the center must be notified by the parent or caregiver before the class or program ends. This will allow us to plan accordingly and to prepare the child for what to expect.

Late Pick-up

All students must be picked up promptly at the end of their designated class or program. If a child is not picked up at dismissal time, they will be signed in at the front desk to the Late Pick-up Sign Out Sheet and the parent/guardian will be contacted. Staff will remain on site until the situation is resolved. If over three hours lapse without being able to contact the parent/caregiver and emergency contact, Child and Family Services (DCFS) will be contacted.

Late Fees

The fee for late pick-up is $15 for every 15 minutes that the authorized pick-up person is late. This amount will be charged to the credit card on file.
I acknowledge the SSAKC pick up policy outlined above. Parent / Guardian signature (type your full name below):

First NameLast Name
Child's Name

First NameLast Name
Relationship to child
Date

MonthDayYear
Date

GENERAL MEDICATION ADMINISTRATION FORM

Please fill in this form, if applicable. Download and print, fill in and upload the completed form.
Upload your completed General Medication Administration Form here

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ASTHMA ACTION PLAN

Please fill in this form, if applicable. Download and print, fill in and upload the completed form.
Upload your completed Asthma Action Plan here

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ALLERGY RESPONSE PLAN

Please fill in this form, if applicable. Download and print, fill in and upload the completed form.
Upload your completed Allergy Response Plan here

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SUPER STARS AFTER SCHOOL KIDZ CLUB - ENROLLMENT AND PERMISSION FORMS

Personal Profile Information

Child Information

Parent Information

Caregiver Information

List two additional contacts in case of emergency

Medical Profile Form

Suplimental Student Needs Plan

Child Health Examination Form

Authorized Escorts List Form

Super Stars Afterschool Kidz Club Waiver Form

Super Stars Afterschool Kidz Club Pick up Policy

GENERAL MEDICATION ADMINISTRATION FORM

ASTHMA ACTION PLAN

ALLERGY RESPONSE PLAN