ALPHA KIDCARE, INC. - CAMPUS KIDCARE
2009-2010 KIDCARE REGISTRATION APPLICATION
I am registering my child for (üCheck all that apply): □Morning Care (If Available) □Afternoon Care □Full-Day Care (***When/If Available)
***Note: Please see the Holiday/Closed/Full Day section on page 4 of this application for further information regarding full-day care.
LIABILITY: KidCare will not be liable for any child who attends any other activity program on or off campus. Once children check into KidCare they must remain with KidCare until someone on their authorized sign in/out form has signed them out. If the child needs to return to KidCare they must be officially signed back in by an authorized adult and they must report directly to the Site Manager upon return.
ABSENCES: Please notify KidCare in the event your child will be absent or other pick up arrangements are made on the days when this change is in effect. This will help us account for all children at roll call.
SIGN-IN AND OUT POLICY: I understand it is my responsibility as parent or guardian bringing my child to KidCare or picking my child up from KidCare to sign in and sign out on the sign in/sign out form. I also understand when someone is picking up my child that he or she must have proper identification, be at least 16 years of age, be on the pick-up list and must sign my child in or out upon bringing or picking up my child to or from KidCare. I understand full legible signatures are required, no initials or nick names can be accepted. I understand if the signature of the person signing is not legible then that person must also print their name next to their signature.
LATE PICK-UP: I understand there is a $1.00 per minute, per child cost to all children who are not picked up by 6:00 p.m. daily and that excessive late pick-ups may result in my child being withdrawn from the KidCare program.
I understand it is my responsibility to update my pick-up list and phone numbers as often as necessary to keep the list current.
PHOTOS AND MEDIA PUBLICATIONS: KidCare may occasionally take pictures of children playing or doing different activities. Some pictures are used to make special art projects or may occasionally be posted throughout KidCare and/or in one of our newsletters or special publications. If you do not want your child to be photographed, please check the appropriate box below so your child’s file can be flagged for NO PICTURES. Otherwise, please check the appropriate box below and sign if you have no objection to your child having his or her picture taken.
CHECK APPROPRIATE BOX □ALLOW PICTURES □DO NOT TAKE PICTURES
By signing, I attest that I have read and fully understand the terms of this agreement and I will comply with all policies and procedures.
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Signature of Parent or Legal Guardian Date

CHILD’S LAST NAME	CHILD’S FIRST NAME	CHILD’S MIDDLE NAME	CHILD’S GENDER: Male/Female	CHILD’S DATE OF BIRTH - MM/DD/YYYY / / /	CHILD’S SOCIAL SECURITY # / _ _ _ - _ _ - _ _ _ _
NAME OF ELEMENTARY SCHOOL CHILD ATTENDS		ROOM #	CHILD’S TEACHER’S NAME		CHILD’S GRADE K-5 / (
CHILD’S PHYSICAL HOME ADDRESS HOUSE NUMBER AND STREET		CITY	STATE	ZIP	CHILD’S HOME TELEPHONE NUMBER # / ( ) -
FATHER’S / GUARDIAN’S / FATHER’S DOMESTIC PARTNER’S - LAST NAME		FIRST NAME	MIDDLE NAME	DATE OF BIRTH - MM/DD/YYYY / / /	FATHER’S HOME PHONE NUMBER # / ( ) -
FATHER’S PHYSICAL HOME ADDRESS HOUSE NUMBER AND STREET		CITY	STATE	ZIP	FATHER’S CELL PHONE NUMBER # / ( ) -
FATHER’S PLACE OF BUSINESS OR WORKPLACE NAME OF COMPANY		ADDRESS	STATE	FATHER’S DRIVER’S LICENSE #	FATHER’S WORK PHONE NUMBER # / ( ) -
MOTHER’S / GUARDIAN’S / MOTHER’S DOMESTIC PARTNER’S - LAST NAME		FIRST NAME	MIDDLE NAME	DATE OF BIRTH - MM/DD/YYYY / / /	MOTHER’S HOME PHONE NUMBER # / ( ) -
MOTHER’S PHYSICAL HOME ADDRESS HOUSE NUMBER AND STREET		CITY	STATE	ZIP	MOTHER’S CELL PHONE NUMBER # / ( ) -
MOTHER’S PLACE OF BUSINESS OR WORKPLACE NAME OF COMPANY		CITY	STATE	MOTHER’S DRIVER’S LICENSE #	MOTHER’S WORK PHONE NUMBER # / ( ) -
CHILD LIVES WITH - LAST NAME		FIRST NAME	MIDDLE NAME	DATE OF BIRTH - MM/DD/YYYY / / /	HOME OR CELL PHONE NUMBER # / ( ) -
LIST ALLERGIES TO ANY FOODS	LIST ALLERGIES TO ANY FOODS	LIST ALLERGIES TO ANY MEDICATIONS	LIST ALLERGIES TO ANY INSECTS	LIST ALL OTHER ALLERGIES	LIST ALL OTHER ALLERGIES / (
NOTE: When you are unavailable at your job location, always notify KidCare that day in case an emergency occurs, of where or how you or an authorized person can be notified.

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SITE MANAGER USE ONLY
Registration Date: ____/____/20____ Start Date: ____/____/20____ Enrolled By (Staff member’s name): ____________________ Contracted Weekly Fee $ ____________
□Paid Registration Fee □Paid Tuition Fee Amount Paid: $_________________ Check or Money Order # _________________ For Week: ____/____/20____
Is Child on a Funding Source? □Yes □No If yes, name of Funding Source? □Arbor □Free Lunch □Reduced Lunch □School Board □Other
If ARBOR, list Arbor Certificate Rates: Part Time Fee $__________ Daily Parent Fee $__________ Weekly Parent Fee $__________ Holiday/Full-Day Parent Fee $________□
Does this child have siblings at this facility? □Yes □No If yes, list name/s: _______________________________________________________________________
Check that parent was given the following: □Know Your Child Care Brochure □KidCare Handbook □Parent Information/Policies □Nutritional Guidelines

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© FM:KRA/FT/EMA Revised June 01, 2009

ALPHA KIDCARE, INC. - CAMPUS KIDCARE
2009-2010 KIDCARE REGISTRATION APPLICATION
(CONTINUED - PAGE 2 of 5)

ADDITIONAL PERSONS WHO MAY BE CALLED IN AN EMERGENCY - Please list ONLY the people we may discuss emergency issues with.
FULL NAME		DATE OF BIRTH - MM/DD/YYYY / / /	HOME PHONE NUMBER# / ( ) -	CELL PHONE NUMBER# / ( ) -	WORK PHONE NUMBER# / ( ) -
STREET ADDRESS		CITY	STATE	ZIP	RELATIONSHIP TO CHILD
FULL NAME		DATE OF BIRTH - MM/DD/YYYY / / /	HOME PHONE NUMBER# / ( ) -	CELL PHONE NUMBER# / ( ) -	WORK PHONE NUMBER# / ( ) -
STREET ADDRESS		CITY	STATE	ZIP	RELATIONSHIP TO CHILD
FULL NAME		DATE OF BIRTH - MM/DD/YYYY / / /	HOME PHONE NUMBER# / ( ) -	CELL PHONE NUMBER# / ( ) -	WORK PHONE NUMBER# / ( ) -
STREET ADDRESS		CITY	STATE	ZIP	RELATIONSHIP TO CHILD

CHILD’S PHYSICIAN OR DENTIST TO BE CALLED BY MEDICAL PERSONNEL IN THE EVENT OF AN EMERGENCY
PHYSICIAN’S NAME		PHYSICIAN’S TELEPHONE NUMBER# / ( ) -	MEDICAL INSURANCE COMPANY NAME AND POLICY #
PHYSICIAN’S ADDRESS - STREET ADDRESS, CITY, STATE, ZIP
DENTIST’S NAME		DENTIST’S TELEPHONE NUMBER# / ( ) -	DENTAL INSURANCE COMPANY NAME AND POLICY #
DENTIST’S ADDRESS - STREET ADDRESS, CITY, STATE, ZIP

OTHER THAN THE CUSTODIAL PARENT OR GUARDIANS - LIST OTHER PERSONS AUTHORIZED TO TAKE CHILD FROM FACILITY (CHILD WILL NOT BE ALLOWED TO LEAVE WITH ANY OTHER PERSON WITHOUT WRITTEN AUTHORIZATION AND VERIFICATION FROM LEGAL PARENT/GUARDIAN OR REPRESENTATIVE. MUST BE OVER 16 YEARS OF AGE.)
FULL NAME		DATE OF BIRTH - MM/DD/YYYY / / /	HOME PHONE NUMBER# / ( ) -	CELL PHONE NUMBER# / ( ) -	WORK PHONE NUMBER# / ( ) -
STREET ADDRESS		CITY	STATE	ZIP	RELATIONSHIP TO CHILD
FULL NAME		DATE OF BIRTH - MM/DD/YYYY / / /	HOME PHONE NUMBER# / ( ) -	CELL PHONE NUMBER# / ( ) -	WORK PHONE NUMBER# / ( ) -
STREET ADDRESS		CITY	STATE	ZIP	RELATIONSHIP TO CHILD
FULL NAME		DATE OF BIRTH - MM/DD/YYYY / / /	HOME PHONE NUMBER# / ( ) -	CELL PHONE NUMBER# / ( ) -	WORK PHONE NUMBER# / ( ) -
STREET ADDRESS		CITY	STATE	ZIP	RELATIONSHIP TO CHILD

LIST ALL KNOWN ALLERGIES
ALLERGY TO ANY MEDICATIONS	ALLERGY TO ANY FOOD	ALLERGY TO ANY PLANTS	ALLERGY TO ANY INSECTS
OTHER	OTHER	OTHER	OTHER
ADDITIONAL INFORMATION OR COMMENTS

LIST ANY DAILY MEDICATIONS (Example: Diabetes, Asthma, Seizure Medicine etc… This information is in the event of an emergency for the medical professionals.) Please notify the center if this information changes.
NAME OF MEDICATION	DOSAGE	REASON FOR TAKING MEDICATION	OTHER INFORMATION OR COMMENTS
NAME OF MEDICATION	DOSAGE	REASON FOR TAKING MEDICATION	OTHER INFORMATION OR COMMENTS

PLEASE LIST ANY COURT ORDERED, SPECIAL CIRCUMSTANCES, MEDICAL, OR OTHER INFORMATION WE NEED TO BE AWARE OF / (DOCUMENTATION MUST BE ATTACHED IN A CONFIDENTIAL ENVELOPE FOR ALL COURT ORDERED OR LEGAL CIRCUMSTANCES)

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© FM:KRA/FT/EMA Revised June 01, 2009

ALPHA KIDCARE, INC. - CAMPUS KIDCARE
2009-2010 KIDCARE REGISTRATION APPLICATION
(CONTINUED - PAGE 3 of 5)

DISCIPLINE POLICY STATEMENT
1. Age appropriate, constructive disciplinary practices are used for children in child care. / A. Discussion with the child about appropriate behavior. / B. “Redirection” to another activity. / C. Discipline form(s) signed by parent/guardian. / D. Consultation with parents to seek answers or understanding of the problem. / E. Suspension / 2. Children are not subjected to discipline which is severe, humiliating or frightening. / 3. Discipline is not associated with food, rest or toileting. / 4. Spanking, or any other form of physical punishment, is strictly prohibited. / At the discretion of the director and after a reasonable effort on the part of the program staff to integrate a child into the program, a child’s participation may be terminated / if that child is deemed chronically disruptive to the functioning of the program. / I have read and fully understand and agree with the above discipline policy. / __________________________________________________ _____________________ / Signature of Parent or Legal Guardian Date

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KNOW YOUR CHILDCARE BROCHURE STATEMENT
On _____/_____/_____, I ____________________________________received and read a copy of the Know Your Child Care Brochure. / (Date) (Print Name of Parent or Legal Guardian) / __________________________________________ ________________________________ _____________________ / Signature of Parent or Legal Guardian Print Name of Child Date

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FEE AGREEMENT STATEMENT
Please read the following carefully: / Children are enrolled for one week sessions. No credits or refunds will be given for absences regardless of the reason. / There is a non-refundable $25.00 registration fee per child. / Tuition payments are due in full and in advance, on Monday of each week or the first day of the week KidCare is open. A $5.00 late fee will be added to any account not paid in full by Tuesday, 6:00 p.m. each week. Since all payments are due in advance, we DO NOT hold payments from immediate deposit. / Full weekly tuition fees are due, regardless of absences, even if your child is out all week. Full weekly tuition fees are due regardless of holidays or when KidCare is closed for storm days. There is an extra charge when KidCare is in session for full day services. ***For more information see the Holiday and Closed information on page 4 of this application. / Fees are due in full each week for children who are on suspension regardless of the reason, this will hold their slot until they return. If suspended for more than one week the parent may wish to withdraw and re-register when space is available. If a child has been suspended from school for any reason that child can not attend KidCare during the suspension. The full weekly fee will be due regardless of the days attended. / If your account has not been paid in full, including late fees by Wednesday, 6:00 p.m. then your child will be withdrawn from the program and will not be able to return to KidCare until your account has been paid in full. Excessive late payments can result in your child being dropped from the program. / Parents on a funding source are required to keep their funding certificate current and for paying any and all fees not covered by their funding source. / You must notify the KidCare site manager one week in advance and in writing if you chose to withdraw your child from the program or your account will be charged the full regular tuition fee. / When paying by check, please print your child’s name and the dates for which you are paying on each payment. All checks must have your full name, complete local/current address & phone number with the local financial institution’s name & address printed on each check. / No child will be admitted to the program who has not been fully registered and all fees paid in advance for the week attending. / A late pick-up charge of $1.00 per minute, per child is assessed if your child/children are not picked-up daily by 6:00 p.m. Late fees are due the day you are late. Excessive late pick-ups will result in your child being dropped from the program. / In the case of a returned check, you will be charged a $5.00 late fee and up to a $35.00 return fee. Only money order or a certified check, will be accepted as prompt repayment on the day you are notified. If unpaid, your child care will be suspended until all fees are paid in full. The return check fee will not be waived for any reason. / After a return check, KidCare will only accept money orders or cashiers check, in advance for tuition fees. / For the safety of our children and staff, only check or money order payments will be accepted at this school site. / We only accept checks drawn on a local bank account. No out of state, temporary, starter, counter or 2nd party checks will be accepted. / Financial assistance may be available to qualifying individuals unable to afford program fees. See your director for more information. / After one week of absence without notice your child will be automatically withdrawn from the program. / Once your child has been withdrawn from KidCare for any reason, in order for your child/children to return to KidCare you must re-register your child with a new registration fee, all new enrollment forms and pay any unpaid fees from previous registration. / It is your responsibility to keep up with your canceled checks and/or receipts for income tax purposes as KidCare does not do end of the year statements. / It is your responsibility to remember to pay your child’s tuition on time and in advance as KidCare does not send out billing. If you would like a receipt, you must get one at time of payment as we do not back log receipts. / One week vacation time can be requested in writing at least one week in advance and during this time your child’s KidCare fee will be waved. / Make checks payable to KidCare. We will not accept altered money orders or checks, this will include checks made out to the wrong party. / I understand it is my responsibility to check the parent board and or all posted signs regarding updates on center policies, KidCare holidays, closed and other parent information or reminders. / I have read and fully understand the terms of this agreement and I will comply with all policies and procedures. / _________________________________________________ ___________________________ / Signature of Parent or Legal Guardian Date

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© FM:KRA/FT/EMA Revised June 01, 2009

ALPHA KIDCARE, INC. - CAMPUS KIDCARE
2009-2010 KIDCARE REGISTRATION APPLICATION
(CONTINUED - PAGE 4 of 5)

MEDICATION POLICY
WE DO NOT GIVE ANY KIND OF MEDICATION. If your child needs medication, you will have to make arrangements to give the medication during your lunch hour, before and or after school. This includes breathing treatments. 911 will be called for all emergencies. KidCare can not transport your child to a medical facility.

ACCIDENT INSURANCE POLICY
Your registration fee pays for an accident insurance policy in case your child gets injured while at KidCare. Our policy is an “excess coverage” policy which means that your primary insurance must pay first. This insurance will pay for most charges not covered by your primary insurance company. However the parent or guardian will be responsible for paying any fees not covered by insurance.

HOLIDAYS / CENTER CLOSED / FULL DAY INFORMATION
KidCare will be closed on the following holidays which will include: New Year’s Day, Martin Luther King’s Birthday, *Presidents Day, *Good Friday, (*Selected sites may be open on President’s Day and/or Good Friday with at least 15 pre paid children signed up by the deadline.), Memorial Day, Independence Day, Labor Day, Veteran’s Day, Thanksgiving and the day after, Christmas Eve and Christmas Day. If the holiday falls on Saturday, then KidCare will be closed on the Friday before the holiday, and if the holiday falls on a Sunday, then KidCare will be closed on the Monday following the holiday. Note: We are sometimes closed due to severe storm warnings or other unforeseen reasons. If the public schools are closed due to severe weather or any other unforeseen reason, then KidCare will also closed because our programs are located on the school grounds. You will normally get this information from your local news station or if time allows you will be notified on the parent information board or by your KidCare director. When school is closed for fall, winter, spring break, staff development days, school site improvement days, or student holiday, selected KidCare sites will take a survey/sign up sheet with a deadline. We must have a minimum of 20 students signed up and paid in advance in order for your KidCare site to be open. If a minimum of 20 is not met by the deadline, the KidCare site will be closed. During these full day times an additional fee and/or an advance payment will be required at the time of sign up, to secure a slot for your child. Children must sign up for these full days in order to attend as we will not take drop-ins. Any child not signed up by the deadline will be unable to attend as we must have an accurate child count in advance to prepare for additional staffing on these full days. There are no deductions in weekly tuition fees if KidCare is closed due to lack of parent participation or other reason. See your KidCare director or parent information next to the sign in and out sheets as these days approach. If KidCare is closed, a closed sign will be posted on the parent information board as well as various locations throughout KidCare 10 days or more prior to the date they will be closed. / PARENTS ARE RESPONSIBLE FOR OBTAINING ALTERNATE CARE FOR THEIR CHILDREN WHEN KIDCARE IS NOT IN SESSION.

HOURS OF OPERATION / LATE PICK-UP POLICY
KidCare is open from 6:30 a.m. until 6:00 p.m. or from 6:30 a.m. until school starts and/or from 2:00 p.m. until 6:00 p.m. Monday thru Friday. When possible you should notify KidCare if you may be late picking up your child. You should notify KidCare if your drop off or pick up time changes. We allow a (10) hour time frame for each child and there will be and extra charge of $2.00 per hour, per child after the first 10 hours of care. There is a late fee of $1.00 per minute, per child, starting at 6:01 p.m. and excessive late pick ups will result in your child being dropped form the program. If a parent or guardian has not picked up their child/children by 6:20 p.m. and no one has called to say they will be late and/or the KidCare site manager is unable to locate someone on the child’s pick-up list to pick up the child, the Department of Children and Families and local police or sheriff’s department will be called to pick-up the child/children.

ABSENCES
Weekly tuition fees are due in full each week regardless of absence, holiday or even if your child is absent all week. If a parent is on a state grant, funding source or scholarship for child care fees, that child should be at KidCare everyday unless an emergency or illness occurs. Most funding sources will only cover from 1 to 3 days of absence per calendar month, depending on the funding source your child is on. If the child is absent more than the allowable days, for whatever the reason may be, the parent will be responsible for paying the regular tuition fees for all fees not covered by their funding source. In some extreme cases an absentee waiver can be signed and submitted for up to an additional 5 days of absence. Along with this waiver a hospital or doctors letterhead with an explanation must accompany this waiver to be considered. However, this does not guarantee payment from the funding source. They are reviewed case by case by the funding agency and only extreme emergencies will be covered. The parent will be required to pay the regular tuition if not paid by the funding source. These fees are from $9.00 to $22.00 per day, per child. Parents/Guardians are responsible for renewing and/or keeping their funding certificate valid at all times while in attendance at KidCare.

INCOME TAX STATEMENTS
KidCare does not issue end of the year income tax statements. It is the responsibility of the parent or guardian to keep your canceled check, money order or cash receipts for your end of the year balance. We will gladly give you a receipt at time of payment if you ask, no matter what form of payment you choose, however you must ask and get your receipt at the time of payment as we do not back log receipts.

NUTRITION AGREEMENT STATEMENT
Parent or guardian must supply each child with a meal which meets the nutritional needs for a child of his/her age group. This will be on the days when the school cafeteria is closed and or on days your child attends KidCare during lunch time. KidCare has provided each applicant with a nutritional guide line and pertinent nutritional/dietary information for each child’s age group. See the parent information sheet on nutritional guidelines.

ACKNOWLEDGEMENT
By signing this acknowledgement, I attest that I have read, fully understand, and agree to all the policies of this company which include the following: Medication Policy, Insurance Policy, Holiday / Center Closed / Full Day Information, Hours of Operation / Late Pick-ups, Absences, Income Tax Statement and Nutrition Agreement Statement. / __________________________________________ ________________________________ _____________________ / Signature of Parent or Legal Guardian Print Name of Child Date

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© FM:KRA/FT/EMA Revised June 01, 2009

FIELD TRIP PERMISSION FORM AND EMERGENCY MEDICAL AUTHORIZATION FORM
Release for Participation in the Alpha KidCare, Inc. - Campus KidCare Program
Child’s Full Legal Name: ____________________________________________ Date of Birth: ____/____/_____ Age:_______ Gender: ________
I do hereby solemnly swear that I(we) ___________________________________________ have legal custody of the aforementioned minor child.
I(we), the undersigned, individually and/or as parent/s and/or legal guardian/s of the aforementioned minor child, ask that he/she be admitted to participate in the Alpha KidCare, Inc. Campus KidCare school-year or summer program and field trip events. In consideration of such admission, I do herby agree to release, discharge, and hold harmless Alpha KidCare, Inc., its officers, agents and employees of and from all causes, liabilities, damages, claims, or demands whatsoever on account of any injury or accident involving the said minor arising out of the minor’s attendance at and/or with the Alpha KidCare, Inc. Campus KidCare program. Non-conformance to Alpha KidCare, Inc. policies and procedures as told to my child by the directors and/or staff may result in dismissal from the program and/or field trip events. My aforementioned minor child has my permission to participate in any of the field trips and center activities. This includes any field trip out of the county that we may take. I have read the parent handbook, parent field trip rules & information and understand completely.
I understand that all field trip information is posted on the parent information board each week and I must sign my child up for each field trip event I wish my child to participate in.
I understand that there may be a separate charge for each field trip and that all field trip monies must be paid in cash, by the due date and paid separate from tuition.
I give my permission for any staff member to apply sun screen to my child as needed during any outside activity whether the center or I have provided the sun screen.
I understand that my child must be at the child care facility at least 45 minutes prior to all field trip departure times or may not attend the field trip.
I may only pick-up and/or drop-off my child at the child care facility to participate in a field trip or event and that my child must ride the facility bus or van to each field trip event.
I understand that there are no refunds unless the trip is canceled for bad weather or other unforeseen reason.
I must notify the director in writing if I do not want my child to participate in a field trip event or center activity that I have signed up for, at least 24 hours prior to the trip or activity.
I understand that a copy of this information will be kept at the facility as well as on the facility bus or van in the event that it is needed.
INSURANCE / ACCIDENT POLICY
I understand that my child’s registration fee pays for an ‘Excess Coverage Accident Insurance Policy’ in the event my child is injured while in the care of Alpha KidCare, Inc. and its employees. I also understand that the policy is an Excess Coverage Policy which means that my primary insurance must pay first and the excess coverage insurance will pay for most charges not covered by my primary insurance company. I understand that I will be responsible for paying any cost or fees not covered by insurance.
EMERGENCY MEDICAL AUTHORIZATION AND CONSENT OF PARENT(S) OR LEGAL GUARDIAN(S)
I grant my authorization and consent for Alpha KidCare, Inc., its officers, agents, staff, or employees (hereafter “Supervising Adult”) to administer general first aid treatment for any minor injuries or illnesses experienced by the minor. If the injury or illness is life threatening or in need of emergency treatment, I authorize the Supervising Adult to summon any and all professional emergency personnel to attend, transport, and treat the participant and to issue consent for any X-ray, anesthetic, blood transfusion, medication, or other medical diagnosis, treatment, or hospital care deemed advisable by, and to be rendered under the general supervision of, any licensed physician, surgeon, dentist, hospital, or other medical professional or institution duly licensed to practice in the state in which such treatment is to occur.
In all emergencies, I understand that 911 will be called. In the event that reasonable attempts to contact me, the undersigned, have been unsuccessful, I hereby give my consent for the administration of any treatment deemed necessary by any licensed physician, surgeon, dentist, hospital, or other medical professional or institution; and the transfer of my child to the preferred hospital or, any hospital reasonably accessible. I understand that the consent and authorization herein granted do not include major surgical procedures unless the medical opinions of two licensed physicians, surgeons, or dentists, concurring in the necessity for such surgery, are obtained prior to the performance of such surgery and are valid only during the time my child is in the care of and in attendance with the Alpha KidCare, Inc. Campus KidCare program. I agree to the release of any records necessary for treatment, referral, billing, or insurance purposes to the appropriate medical care provider.
It is understood that this authorization is given in advance of any such medical treatment, but is given to provide authority and power on the part of the Supervising Adult in the exercise of his or her best judgment upon the advice of any such medical or emergency personnel.

A completed and notarized Field Trip Permission and Emergency Medical Form is required for each child participating in the Alpha KidCare, Inc. Campus KidCare school-year or summer program. Please print in ink or type only. Fill in all sections. This form as well as all child information forms may be copied for use on the facility bus or van in the event that it is needed.
- Must Be Completed by Custodial Parent/s or Legal Authorized Representative. Notify Facility Immediately if any Information Changes. -

CERTIFICATE OF ACKNOWLEDGMENT OF CUSTODIAL PARENT OR LEGAL GUARDIAN
By signing this form, I attest that I have read, fully understand and agree to comply with the terms and conditions in this agreement, as well as the policies and procedures of this company. / This authorization is effective commencing on the ______day of _________________, 20____ and expiring on the 30th day of August, 2010. / Signed this ______day of____________________, 20 ____. / ______________________________________ ______________________________________ / Custodial Parent or Legal Guardian #1’s Signature Custodial Parent or Legal Guardian #2’s Signature if Applicable

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CERTIFICATE OF ACKNOWLEDGMENT OF NOTARY PUBLIC
In the State of _______________, in the County of ____________. This document was acknowledged before me this ______day of _________________, 20____. / Before me, _____________________________ (person/s signing) signed this document, who was identified by use of ___________________________(ID used) or is personally known to me. / ___________________________________________________ My Commission Expires: (Signature of Notary Officer) (Notary Seal or Stamp) Notary Public for the State of Florida

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© FM:KRA/FT/EMA Revised June 01, 2009

NUTRITIONAL GUIDELINES
FOR CHILDREN FROM AGES 1 TO 12

FOODS FOR CHILDREN		AGES 1-3		AGES 3-6		AGES 6-12
BREAKFAST
MILK		1/2 CUP		3/4 CUP		1 CUP
JUICE, FRUIT OR VEGETABLE		1/4 CUP		1/2 CUP		1/2 CUP
BREAD OR *BREAD ALTERNATE		1/2 SLICE		1/2 SLICE		1 SLICE
*CEREAL, COLD DRY		1/4 CUP OR 1/3 OZ.		1/3 CUP OR 1/2 OZ.		3/4 CUP OR 1 OZ.
*CEREAL, HOT COOKED		1/4 CUP		1/4 CUP		1/2 CUP
SNACK / Select 2 out of the 4 components:
MILK		1/2 CUP		1/2 CUP		1 CUP
JUICE, FRUIT OR VEGETABLE		1/2 CUP		1/2 CUP		3/4 CUP
MEAT OR MEAT ALTERNATE		1/2 OUNCE		1/2 OUNCE		1 OUNCE
BREAD OR *BREAD ALTERNATE		1/2 SLICE		1/2 SLICE		1 SLICE
*CEREAL, COLD DRY		1/4 CUP OR 1/3 OZ.		1/3 CUP OR 1/2 OZ.		3/4 CUP OR 1 OZ.
*CEREAL, HOT COOKED		1/4 CUP		1/4 CUP		1/2 CUP
LUNCH OR SUPPER
MILK		1/2 CUP		3/4 CUP		1 CUP
MEAT, POULTRY, FISH OR *		1 OUNCE		1 1/2 OUNCE		2 OUNCES
*EGG		1		1		1
*CHEESE		1 OUNCE		1 1/2 OUNCE		2 OUNCES
*COOKED DRY BEANS OR PEAS		1/4 CUP		3/8 CUP		1/2 CUP
*PEANUT BUTTER		2 TABLESPOONS		3 TABLESPOONS		4 TABLESPOONS
VEGETABLES AND/OR FRUITS**		1/4 CUP		1/2 CUP		3/4 CUP
**(TO TOTAL 2 OR MORE)
BREAD OR BREAD ALTERNATE		1/2 SLICE		1/2 SLICE		1 SLICE
When packing your child’s lunch, please remember that the Center is not allowed to do any cooking and are not allowed to heat food in the microwave, so it is best to pack lunches that do not require heating. The Center will supply a drink for your child at meal time. Your child’s lunch should be nutritionally balanced and ready to eat. Please see your director if you need further information about lunches or lunch times. / Thank You