KYDS VILLAS REGISTRATION

KYDS VILLAS REGISTRATION
CHILD(REN) INFORMATION
FIRST and LAST NAME, DOB and GENDER (M or F)*
Ex. Todd Charleston 7/25/13 M
FIRST and LAST NAME, DOB and GENDER (M or F)
Ex. Tom Souher 9/18/15 M
FIRST and LAST NAME, DOB and GENDER (M or F)
Ex. Alison Zulecki 1/10/17 F
FIRST and LAST NAME, DOB and GENDER (M or F)
Ex. Charlotte Ewing 3/2/18 F
SPECIAL NEED(S)
MEDICATION(S)*
List medication for your child(ren) with their name or N/A
ALLERGIES*
List allergies for your child(ren) with their name or N/A
CHILD(REN) EMERGENCY INFORMATION
RELATIONSHIP TO CHILD*
Ex. Grandparent, uncle, brother, aunt, family friend, etc.
CONTACT'S PHONE NUMBER*
1ST PARENT/ GUARDIAN INFORMATION
Name

First NameLast Name
RELATIONSHIP TO CHILD*
CELL PHONE*
WORK PHONE
EMAIL*
example@example.com
2ND PARENT/ GUARDIAN INFORMATION
Name

FIRST NAMELAST NAME
RELATIONSHIP TO CHILD
CELL PHONE
WORK PHONE
EMAIL
example@example.com
I, GIVE MY PERMISSION FOR MEDICAL EMERGENCY TREATMENT OF MY CHILD FOR ILLNESS OR ACCIDENT IF I CANNOT BE CONTACTED

AGREEDISAGREE
PARENT/ GUARDIAN NAME:*
First & Last Name
DATE*

MonthDayYear
Date
PARENT/ GUARDIAN SIGNATURE*

Clear
BY SIGNING THIS ENTIRE FORM, I ACKNOWLEDGE THAT I HAVE READ, UNDERSTAND & AGREE AND CERTIFY THAT ALL INFORMATION DOCUMENTED IS ACCURATE TO THE BEST OF MY KNOWLEDGE.
PICK-UP & DROP-OFF INFORMATION
The following persons (INCLUDE YOURSELF) have my permission to pick up my child from Kyds Villas facilities.
NAME*
PHONE NUMBER*
RELATIONSHIP*
NAME
PHONE NUMBER
RELATIONSHIP
NAME
PHONE NUMBER
RELATIONSHIP
Late Policy: Please be on time. There is a 10-minute grace period for emergencies. After the grace period you will be charged $1 per minute. The total amount on the day of service(s)/prior to any other service(s) being rendered.*

Agree
CHOOSE A (5-DIGIT) TELEPHONE PASSCODE NUMBER:
IMPORTANT: WE will NOT speak to or give out ANY INFORMATION to anyone over the phone about your child if they DO NOT have and/or provide Kyds Villas with this special TELEPHONE PASSCODE NUMBER that you've chosen above!
(5-DIGIT) TELEPHONE PASSCODE*
The following PERSON DOES NOT have my permission to pick up my child from Kyds Villas facilities.
First and Last Name
MEDICATION POLICY
I agree and understand that if my child requires medication given during the time and hours he/she is at the Kyds Villas during their reservation, that I know to ONLY bring the EXACT number of pills/prescription for the reservation time (no more/no less ALL MEDICINE MUST BE IN THE/IN A PHARMACY BOTTLE WITH PHARMACY LABEL ON IT WITH YOUR CHILDS NAME, DOCTORS NAME, DOCTORS NUMBER/PHARMACY NUMBER, RX #, DOSAGE, DRUG NAME AND DATE.

AGREE
I agree and understand that in the event my child/children requires immediate medical attention that I authorize Kyds Villas to call 911 and assist (logistically) in the transfer to a nearest ER in the event that I cannot make it back to the facility in enough time to transport my child/children myself. I also agree and authorize Kyds Villas to provide basic first aid in case my child/children incur an unfortunate injury. In the event my child/children chokes or experiences heart or lung failure, I authorize Kyds Villas to perform basic first aid/CPR with the direction of the 911 dispatch (Kyds Villas staff/YCPAs are certified in CPR/First Aid). For the safety of everyone at Kyds Villas, I agree and understand that I must notify Kyds Villas if my child is sick, has a health condition, or has come in direct contact with anyone known with an infectious disease and I agree to keep my child/children home until they are medically cleared. If medical care is needed, call:*

AGREEDISAGREE
If medical care is needed, call:*

First NameLast Name
CONTACT'S PHONE NUMBER*
Please enter a valid phone number.
WAIVER OF LIABILITY INFORMATION
I understand and agree that I am a KYDS VILLAS/YCPA customer/client and my child is also a YCPA customer/client. KYDS VILLAS shall not be liable to KYDS VILLAS/YCPA customer/client on account of any personal injuries and/or any unforeseen death sustained by YCPA customer/client in performance of playing and/or not keeping and maintaining their personal safety on any KYDS VILLAS/YCPA facilities hereunder. I shall indemnify and hold YCPA, harmless from all liability for personal injuries directly related to the playing and/or being on the premises in any KYDS VILLAS/YCPA facility (this may include any games such as water ballooning, laser tag, dodgeball, nerf wars, swimming, field trips etc.). Customer/client is recommended to have personal insurance coverage for all injuries, illnesses or fatalities. KYDS VILLAS/YCPA will not be held responsible for any of your or your child's personal items that are lost, stolen or damaged during your and/or your child's stay/visit with KYDS VILLAS/YCPA. Review other items NOT to bring to KYDS VILLAS/YCPA facilities (please do not send your child to the KYDS VILLAS with expensive jewelry, money, games, toys etc.*
PARENT/ GUARDIAN MUST TYPE First and Last Name
PARENT/ GUARDIAN SIGNATURE*

Clear
I, CONSENT TO PUBLISH ALL PHOTOGRAPHS, MOTION PICTURES AND/OR VIDEOS FOR ANY AND ALL KYDS VILLAS/ YCPA RELATED EXHIBITIONS, PUBLIC DISPLAYS, PUBLICATION AND/OR ADVERTISING PURPOSES WITHOUT LIMITATION*

AGREEDISAGREE
I have successfully read, agree and fully understand 100% all the above pages (including this page) and agree to all rules and policies of YCPAs and Kyds Villas. I understand that this agreement and application can be terminated at any time should any caused safety measures be compromised from myself, my child/children or any other persons I authorize to drop off or pick up, to the company of Kyds Villas. I understand that Kyds Villas reserves the right to refuse service to any one at any time for any reason.*
PARENT/GUARDIAN FIRST and LAST NAME
PARENT/ GUARDIAN SIGNATURE*

Clear
Create a Kyds Villas ACCESS phrase (this gives you access to reserve respite)
i.e. "so far so good" "just do it" etc (must be at least 6 characters).
TODAYS DATE*

MonthDayYear
Date
Should be Empty:

KYDS VILLAS REGISTRATION

CHILD(REN) INFORMATION

CHILD(REN) EMERGENCY INFORMATION

1ST PARENT/ GUARDIAN INFORMATION

2ND PARENT/ GUARDIAN INFORMATION

PICK-UP & DROP-OFF INFORMATION

CHOOSE A (5-DIGIT) TELEPHONE PASSCODE NUMBER:

MEDICATION POLICY

WAIVER OF LIABILITY INFORMATION