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KPL - Enrollment Form
25-26
Family Unique ID
Other Info
Parent/Guardian/Caregiver Information
1) Parent/Guardian/Caregiver's Name
*
First Name
Last Name
Parent/Guardian Type
*
Parent
Guardian
Grandparent
Relative
Other
2) Parent/Guardian/Caregiver's Name
First Name
Last Name
Parent/Guardian Type
Parent
Guardian
Grandparent
Relative
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?
*
Spanish
English
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 Name
Last Name
Child's Date of Birth
*
-
Month
-
Day
Year
Date
Allergies or other concerns:
2. Child's Name
First Name
Last Name
Child's Date of Birth
-
Month
-
Day
Year
Date
Allergies or other concerns:
3. Child's Name
First Name
Last Name
Child's Date of Birth
-
Month
-
Day
Year
Date
Allergies or other concerns:
4. Child's Name
First Name
Last Name
Child's Date of Birth
-
Month
-
Day
Year
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 Name
Last 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?
*
Yes
No
Smart Start Rowan - KPL Waivers & Permissions
Kaleidoscope Play & Learn Participation Agreement: (Please select each box to indicate agreement.)
*
I will participate & interact with my child to promote learning though play at home and in group.
I will use handout information and ideas at home as they are relevant to my family.
I will notify the facilitator in advance whenever I am not able to attend.
I will not participate if either myself or anyone in my household is sick which includes having a fever of 100 degrees of higher within the last 24 hours.
I will use positive and appropriate words and actions when correcting my child's behavior and in my interactions with other parents.
I will not share personal information outside of the group.
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.
*
I Understand and Accept
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 Understand and Accept
I DO NOT grant permission to use videos/photos of me or more child(ren)
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.
*
I Understand and Accept
Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: