KPL Enrollment Form - Bilingual 25-26 (rev)

KPL - Enrollment Form

25-26
Family Unique ID
Other Info
Parent/Guardian/Caregiver Information
1) Parent/Guardian/Caregiver's Name

First NameLast Name
Parent/Guardian Type

Other
2) Parent/Guardian/Caregiver's Name

First NameLast Name
Parent/Guardian Type

Other
Contact Information
Primary Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
What primary language is spoken at home?

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 NameLast Name
Child's Date of Birth

MonthDayYear
Date
Allergies or other concerns:
2. Child's Name

First NameLast Name
Child's Date of Birth

MonthDayYear
Date
Allergies or other concerns:
3. Child's Name

First NameLast Name
Child's Date of Birth

MonthDayYear
Date
Allergies or other concerns:
4. Child's Name

First NameLast Name
Child's Date of Birth

MonthDayYear
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 NameLast Name
Home/Cell Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Does this person have permission to pick up your child in an emergency?
Smart Start Rowan - KPL Waivers & Permissions
Kaleidoscope Play & Learn Participation Agreement: (Please select each box to indicate agreement.)
I understand that I am responsible for my child(ren) during the Kaleidoscope Play and Learn Group. I agree to follow all playgroup rules and the facilitator’s instructions to help keep everyone safe.
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 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.
Signature
Date

MonthDayYear
Date
Should be Empty:

KPL - Enrollment Form

Parent/Guardian/Caregiver Information

Contact Information

Child(ren's) Information

Emergency Contact

Smart Start Rowan - KPL Waivers & Permissions