Kid Zone 2024-2025 School Year Registration

Enrollment & Health Information
Child Information
Child Name

First NameLast Name
Name child goes by
Child DOB
First Date of Attendance
Has child attended Kid Zone previously?

YesNo
Parent or Guardian Information
a. Parent or Guardian

First NameLast Name
Home/ Cell Phone No.
Please enter a valid phone number.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Does Child Reside at This location?

YesNo
Place of Employment
Work Phone No.
Please enter a valid phone number.
b. Parent or Guardian

First NameLast Name
Home/ Cell Phone No.
Please enter a valid phone number.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Does Child Reside at This location?

YesNo
Place of Employment
Work Phone No.
Please enter a valid phone number.
Authorized Persons

Persons other than parents/ guardians who are authorized to pick up the child or accept the child if dropped off.
a. Name

First NameLast Name
Relationship to Child
Phone Number
Please enter a valid phone number.
Email
example@example.com
Place of Employment
Work Phone No.
Please enter a valid phone number.
b. Name

First NameLast Name
Relationship to Child
Phone Number
Please enter a valid phone number.
Email
example@example.com
Place of Employment
Work Phone No.
Please enter a valid phone number.
Emergency Contact

The person to be notified in an emergency when parents/ guardians cannot be reached.
This person is authorized to pick up the child.

YesNo
Name

First NameLast Name
Relationship to Child
Phone Number
Please enter a valid phone number.
Email
example@example.com
Place of Employment
Work Phone No.
Please enter a valid phone number.
Kid Zone Schedule & Fees

Tuition is due Monday of the current week, and Kid Zone reserves the right to cancel enrollment, if fees are not paid by the due date. It is the parent/ guardian's responsibility to contact Kid Zone in the event my child will be absent. I acknowledge that by registering my child(ren) for Kid Zone, I am committing to paying for the reservation slot, regardless of any unforeseen circumstances, including illness. While Kid Zone recognizes that extenuating circumstances may arise, any exceptions to this policy must be approved by the director on a case-by-case basis. Repeated failure to pay in a timely manner can result in my child’s dismissal from Kid Zone. If you need to cancel your enrollment, a 3 week notice is required, during which time your payment is required. Weekly Fees will be prorated on days that the district/ building is closed. There are no daily or hourly fees offered for Kid Zone.
My child receives Wisconsin Shares

yesno
Kid Zone Program Weekly Fee Selection

Kid Zone 3 Year Old - pick up after 2:21pm $230.00 Weekly FeeKid Zone 3 Year Old - pick up at or before 2:21pm $190.00 Weekly FeeKid Zone 4 or 5 Year Old - pick up after 2:21pm $220.00 Weekly FeeKid Zone 4 or 5 Year Old - pick up at or before 2:21pm $180.00 Weekly FeeKid Zone K5- Age 12 After School Program 10 or more hours $80.00 Weekly FeeKid Zone K5- Age 12 After School Program 9 or less hours $55.00 Weekly Fee
Days of Attenance

MondayTuesdayWednesdayThursdayFriday
Arrival Time

Hour Minutes

AM/PM Option
Departure Time

Hour Minutes

AM/PM Option
Physician or Medical Facility
Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Health History and Emergency Care Plan

If available please submit any health care plan information from the child's physician, therapist, etc.
1. Check any special medical condition that your child may have.

No specific medical conditionAny disorder, including Cognitively Disabled, LD, ADD, ADHD, or AutismAsthmaCerebral Palsy/ motor disorderDiabetesEpilepsy/ seizure disorderGastrointestinal or feeding concernsSpecial Diet/ SupplementsMilk Allergy (a statement from a medical professional indicating the acceptable alternative is required)Other conditions requiring special care (list below)Food allergies (specify foods below)Non-Food allergies (specify below)
Triggers that may cause problems
Signs or symptoms to watch for
Steps the staff should follow. If medication is necessary, please submit an authorization to administer medication form.
List any staff to whom you have given specialized training/ instructions to help treat Symptoms.
When to call parents/ guardians regarding symptoms or failure to respond to treatment.
When to consider that the condition requires emergency medical care or reassessment?
Any additional information you would like us to know that could be helpful to staff.
Please upload a current Immunization Record for your child.

Cancelof
A Child Health Report is due every 12 months for children ages 3-5 in addition to the immunization record.
Permission to Release Media
Use includes the display, distribution, publication, transmission, or otherwise use of photographs, images, and/or video taken of my child for use in materials that include, but may not be limited to, printed materials such as brochures and newsletters, videos, ProCare App, social media, and digital images such as those on the Web site.

grant permissiondeny permissiondeny permission - but it is ok to publish pictures in the ProCare Parent App.
Authorizations
I hereby give my consent for emergency care or treatment to be used only if I cannot be reached immediately.

YesNo
I have had an opportunity to review the policies of the child care center and a summary of the Wisconsin Rules for Licensing Child Care Centers.

YesNo
I give my permission for my child to participate in Walking Field Trips and other activities during operating hours. (An additional permission slip is always required for any off site field trips) Kid Zone does not take transported field trips.

YesNo
I have been informed of the number of pets in the center. (The Academy, Camp Explore and Kid Zone do not have any pets)

YesNo
I authorize the center to apply sunscreen to my child.

YesNo
I authorize the center to allow my child to self - apply sunscreen.

YesNo
The center provides and uses 50spf of various brands of sunscreen. I authorize my center to use any brand of sunscreen with an ingredient strength of 50spf.

YesNo
If no, you will be responsible for providing sunscreen for your child. Please bring on your child's first day of attendance, labeled with your child's name. Please indicate the brand name and ingredient strength.
I authorize the center to apply insect repellent to my child.

YesNo
I authorize the center to allow my child to self - apply insect repellent.

YesNo
The center provides and uses 5% picaridin of various brands of insect repellent. I authorize my center to use any brand of insect repellent with an ingredient strength of 5% picaridin.

YesNo
If no, you will be responsible for providing insect repellent for your child. Please bring on your child's first day of attendance, labeled with your child's name. Please indicate the brand name and ingredient strength.
Additional Authorizations

Please read and check each authorization and/ or release.
(This authorization must be checked and signed below before children may attend Kid Zone)

I hereby state that the enrollment information is accurate and complete, I understand that it is my responsibility to provide any changes/updates regarding emergency and health information to Kid Zone/ The Academy. I further understand that failure to provide accurate, complete and updated information may jeopardize my child's registration and or participation in Kid Zone/ The Academy.I further understand that Kid Zone fees do not include accident or illness insurance and Kid Zone/ The Academy is not responsible for any expenses incurred and I agree to release any records necessary for insurance purposes. A separate Immunization record for each child is required prior to participation.Children with special needs or challenges will be accepted provided that reasonable accommodations can be made for their participation in the program and/or the child’s participation does not require an inordinate amount of staff time that would allow for the safety and welfare for the other children in the program. I understand that if my child requires a significant amount of one on one attention, whether due to special needs or behavior, my child may be removed from the program.I understand that my child must be picked up by the program closure (5:30pm), or a late pick-up fee of $1.00 each additional minute will be charged to me.I have read and understand that tuition is due on each Monday, and Kid Zone reserves the right to cancel enrollment, if fees are not paid by the due date. I understand that it is my responsibility to contact Kid Zone in the event I must cancel my child's enrollment. I acknowledge that by registering my child(ren) for Kid Zone, I am committing to paying for the reservation slot, regardless of any unforeseen circumstances, including illness. I understand If I need to cancel my child's enrollment, a 3 week notice is required, during which time your payment is required.While Kid Zone recognizes that extenuating circumstances may arise, any exceptions to this policy must be approved by the director on a case-by-case basis.I understand that all reasonable safety precautions are taken by Kid Zone/ The Academy in the operation of its facility, equipment, and programs. I agree that my child’s participation in the Kid Zone program shall be undertaken at his/her sole risk, and that Kid Zone/ The Academy, its directors, employees, and volunteer staff shall not be liable for my child or his/her property, arising out of or connected to participation in Kid Zone.I understand that in the event medical intervention is needed, every attempt will be made to immediately contact the emergency persons listed. In the event they cannot be reached, I give my consent for Kid Zone/ The Academy staff to act on my behalf in granting permission for my child to receive emergency treatment.These authorizations and policies constitute the full understanding of the parties hereto and no change, modification or waiver of any of these policies shall be effective unless in writing and signed by both parties.Kid Zone is open all days that Goodland Elementary is open, with the exception of November 15th, 2024.Kid Zone Preschool and Kid Zone School Age classroom operation are subject to enrollment numbers. If a classroom does not have the minimum number of children enrolled we will not be able to operate the program in that classroom.
Care on Days off of School
My Child will attend The Academy (9605 Spring Street Mt Pleasant, WI 53406) on days off of school.

YesNo
Which Dates you are interested in your child attending?(Check all that apply)

September 27th, 2024October 18th, 2024November 4th, 2024November 5th, 2024November 27th, 2024December 26th, 2024December 27th, 2024December 30th, 2024January 2nd, 2025January 3rd, 2025January 20th, 2025January 24th, 2025February 17th, 2025March 11th, 2025March 17th, 2025April 4th, 2025April 21st, 2025April 22nd, 2025April 23rd, 2025April 24th, 2025April 25th, 2025May 16th, 2025Summer 2025 (June-August)
Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Enrollment & Health Information

Child Information

Parent or Guardian Information

Authorized Persons

Emergency Contact

Kid Zone Schedule & Fees

Physician or Medical Facility

Health History and Emergency Care Plan

Permission to Release Media

Authorizations

Additional Authorizations

Care on Days off of School