CAMPUS KIDCARE
2008-2009 KIDCARE REGISTRATION APPLICATION
Thank you for choosing the KidCare program this year! Your participation is important to us.
I am registering my child for (Circle 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.
CHILD’S NAME: _________________________________________ Sex:______ Age:______ Birth Date:_____/______/______
School Name:________________________________________ Room #:_______Grade:______ Teacher:_____________________
Home Address:_______________________________________________City:________________State:_________Zip:_________
Home Phone:__________________________ Cell Phone:__________________________ Other:___________________________
Who does child live with? Name:_____________________________________________ Relationship:______________________
Mother/Guardian:______________________________________Father/Guardian:_______________________________________
Driver License #:__________________________State:_______ Driver License #:__________________________ State:________
D.O.B.:____/____/____ D.O.B.:____/____/____
Workplace:__________________________________________ Workplace:____________________________________________
Work Phone:_________________________________________ Work Phone:__________________________________________
Cell/Other:___________________________________________ Cell/Other:___________________________________________
Emergency Contact Person:_____________________________________________________Phone:________________________
(Other than Parent/Guardian)
Are there any unusual circumstances including custody issues we should be aware of? (_____)Yes (_____)No If yes, explain and attach a certified copy of any court order that you have with this application:____________________________________________
HEALTH INFORMATION
Name of Child’s Doctor:________________________________________________Doctor’s Phone:________________________
Name of Medical Facility Doctor Works:________________________________________________________________________
Name of Dentist/Orthodontist:___________________________________________D/O Phone:____________________________
Should your child be restricted from any activities? (______) Yes (______)No If yes, list:______________________________ _________________________________________________________________________________________________________
Does your child have food, medication or other allergies? (_____)Yes (_____)No If yes, list: (Foods):______________________
__________________________ (Medications):__________________________________ (Other):__________________________
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.

Applicant’s Weekly Fee
$_____________

SITE MANAGER USE ONLY
Registration Date:_____________________ Start Date:_____________________ Enrolled By:__________________________________
Amount Paid: $________________ Check #:___________ Registration Fee Paid:$_______________ Check #:__________ For Week #:____________
Is Child on a Funding Source? (_______)Yes (_______)No If yes, list fees: Part Time Day/Week $____________________/$___________________
Name of Funding Source: _____ARBOR _____Other - _______________________________ or Reduce Lunch?____________ Free Lunch?____________
Does this child have siblings at this facility? (_____)Yes (_____)No If Yes, Name/s:____________________________________________________________
Was parent given these: Know Your Child Care Brochure:___________ KidCare Handbook:___________ Parent Information/Policies:____________

Online Registration Form

Page 1 of 5

Revised August 12, 2008

EMERGENCY/PICK-UP AUTHORIZATION LIST:
Date:___________________________
Child’s Name:_______________________________________________________________ Date of Birth:________/_______/_______
Time child will arrive at the Center:__________________________ Time child will be picked up:_____________________________
Parent/Guardian’s Names and phone numbers:
(Mother/Guardian)__________________________________________________________ Home Phone__________________________
Work Phone_______________________________ Cell Phone____________________________ Other _________________________
(Father/Guardian)___________________________________________________________ Home Phone_________________________
Work Phone_______________________________ Cell Phone____________________________ Other _________________________
Persons authorized to pick up my child other than the above parent or guardians: (Children cannot be released to persons under 16 years of age.) List as many as possible and remember if you have more than one job you should list all you can. If you or your authorized pick-up persons have a cell phone you should also list those. If you or any of your emergency people change jobs or phone numbers we need to be notified immediately of the change so that the childs file can be updated. In the event of an emergency we need to be able to reach someone that we can discuss the emergency issue with so please only list those persons to whom we can discuss these issues.
Name_________________________________Relationship________________Home phone_________________Work phone__________________Other________________
Name_________________________________Relationship________________Home phone_________________Work phone__________________Other________________
Name_________________________________Relationship________________Home phone_________________Work phone__________________Other________________
Name_________________________________Relationship________________Home phone_________________Work phone__________________Other________________
Name_________________________________Relationship________________Home phone_________________Work phone__________________Other________________
Name_________________________________Relationship________________Home phone_________________Work phone__________________Other________________
Please list any special circumstances:__________________________________________________________________________________
________________________________________________________________________________________________________________
Every attempt will be made to contact you, the parent, guardian or designated person in charge in the event of an emergency. However, in the event of a serious emergency the Polk County Emergency Medical Service (911) will be called to administer treatment and transport to the nearest emergency medical facility for treatment. Please note that KidCare can not transport your child for any medical treatment.
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 someone can be notified.
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.
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 will 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.
I have read and fully understand all the above information.
_______________________________________________________ _______________________
Signature of Parent or Legal Guardian Date
KidCare may occasionally take pictures of children playing or doing different activities. Some pictures are used to make special art projects or these photos 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 _______________________
Signature of Parent or Legal Guardian allowing pictures Date

Online Registration Form

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Revised August 12, 2008

DISCIPLINE POLICY STATEMENT
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
Children are not subjected to discipline which is severe, humiliating or frightening.
Discipline is not associated with food, rest or toileting.
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 agree with the above discipline policy.
_____________________________________________________________ _________________________
Signature of Parent or Legal Guardian Date

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 Name of Child Date

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. The current 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.
7. 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.
10. 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.
13. After a return check, KidCare will only accept money orders or cashiers check, in advance for tuition fees.
14. For the safety of our children and staff, only check or money order payments will be accepted at this school site.
15. We only accept checks drawn on a local bank account. No out of state, temporary, starter, counter or 2nd party checks will be accepted.
16. Financial assistance may be available to qualifying individuals unable to afford program fees. See your director for more information.
17. After one week of absence without notice your child will be automatically withdrawn from the program.
18. 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.
19. 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.
20. 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.
21. 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.
22. Make checks payable to KidCare. We will not accept altered money orders or checks, this will include checks made out to the wrong party.
23. 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 this agreement and I will comply with these policies and procedures.
____________________________________________________________________________ ___________________________
Signature of Parent or Legal Guardian Date

Online Registration Form

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Revised August 12, 2008

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.

INSURANCE/ACCIDENT 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 or spring break, staff development days, school site improvement days, or student holiday, each KidCare site will take a survey/sign up sheet with a deadline. We must have a minimum of 15 students signed up and paid in advance attending during these times in order for your KidCare site to be open. If a minimum of 15 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. 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-UPS
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 includes 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 Date

Online Registration Form

Page 4 of 5

Revised August 12, 2008

NOTARIZED MEDICAL AUTHORIZATION
I ____________________________________hereby authorize KidCare staff to seek Polk County Medical
Please print the legal guardian’s full name.
Services for treatment and or transport to the nearest emergency medical facility for any and all medical
help needed for my child, ______________________________________ in the event of an accident. I
Please print the child’s full name.
understand that KidCare staff cannot transport a child to any medical facility.
_______________________________________________
Signature of Parent or Legal Guardian
Subscribed and sworn to me this___________ day of ____________________, _________.
_______________________________________________ _______________________________________
Notary Signature Notary Stamp
#_________________________________________________________
Please list the identification used or personally known.

Notary Seal If Applicable

Page 5 of 5

Online Registration Form

Revised August 12, 2008