• CHILD ENROLLMENT AND HEALTH INFORMATION FOR CHILD CARE

    • Child Information 
    • Date of Birth*
       / /
    • Parent/Guardian Information 
    • Format: (000) 000-0000.
    • Format: (000) 000-0000.
    • Format: (000) 000-0000.
    • Format: (000) 000-0000.
    • Format: (000) 000-0000.
    • Format: (000) 000-0000.
    • 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.
    • My child may be be released to this emergency contact.*
    • Format: (000) 000-0000.
    • Format: (000) 000-0000.
    • My child may be be released to this emergency contact.
    • Child Information 
    • Is your child school-age and enrolling for Before / After Care?
    • Does your child have a chronic health condition or diagnosis that requires the program to: observe or monitor symptoms, administer medication, serve medical foods, perform medical procedures, avoid specific foods/environmental conditions/activities, or allow a school age child to carry and administer their own medication?
    • My child will receive specialized/individual services at the program:
    • 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 CONCERN If 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:

    • Permissions & Waivers 
    • Permission to secure emergency transportation.

    • 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.

    • By signing this form, I attest that the information is accurate and that I have reviewed and received a copy of the program’s policies and procedures (parent handbook).

    • Date
       / /

  • Child and Adult Care Food Program (CACFP)

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

    • Please select the days normally in care.
    • Drop Off Time
    • Pick Up Time
    • Meals received while in care.
    • Drop Off Time
    • Pick Up Time
    • Meals received while in care.
    • Drop Off Time
    • Pick Up Time
    • Meals received while in care.
    • Drop Off Time
    • Pick Up Time
    • Meals received while in care.
    • Drop Off Time
    • Pick Up Time
    • 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.
    • First Child's Birthday
       - -
    • Foster child?
    • Do you need to add an additional child?
    • Second Child's Birthday
       - -
    • Foster child?
    • Do you need to add an additional child?
    • Third Child's Birthday
       - -
    • Foster child?
    • Do you need to add an additional child?
    • Fourth Child's Birthday
       - -
    • 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.
  • Signer's Birthday
     - -
  • Date
     - -

  • Registration Payment

    prevnext( X )
      Registration

      Registration fee per family

      $30.00$30.00
        
      Total
      $0.00$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.
    • Should be Empty: