Any person who will take responsibility for the child and/or permission to pick up the child in an emergency when the parent/guardian cannot be reached. At least one contact must be given.
The following information is used for United Way Beneficiary Statistics. The information provided is kept strictly confidential and is used for demographic purposes only.
Please list any health problems which our caregivers should know:
In the event I cannot be reached to make arrangements, I herby consent Kids Can to contact my physician by initialing below.
If eligible for Title XX, please fill out the following information:
I give my child permission to ride the van to and from school to Kids Can on the days that they are registered. Groups will also be taking field trips periodically and this form also serves as authorization to ride the van for a pre-arranged field trip destination. Every child will need to be picked up at Kids Can when the program is over.
I hereby confer the Kids Can the right and permission with respect to photographs and/or videos taken of my child or those in which they may be included as a group, as well photographs of their art work. I hereby release and discharge the Kids Can from any and all claims and demands ensuing from or in connection with the use of the photographs and/or videos, including any and all claims for libel and invasion of privacy. This authorization and release shall inure to the benefit of the legal representatives, licenses and assigns of the Kids Can as well as the person(s) for whom they took the photographs and/or videos. I have read the foregoing and fully understand the contents hereof. I represent that I am the parent/guardian of the child listed above and hereby consent to the foregoing on their behalf.
Each child requires an annual individual registration fee of $25 (or $40 for 2 or more children). All programs are pre-pay; payment must be received no later than Monday of each week. If payment is not received by Monday, a $5 late fee will be applied to each outstanding day. If payment and late fees are still not received by the following Monday, your child will not be able to return to the program. All returned checks will be billed a $20 fee. A deposit is required and ensures your child’s reservation in the program and also acts as the last week’s payment.
Please let staff know the day(s) your child will be attending the program at least 24-hours in advance. Otherwise, we cannot guarantee your child a place in the day’s program. If we are able to accommodate your child on same-day drop-in basis, you will be billed an additional $10 for the day. This arrangement is necessary for our staffing, supplies, food and transportation.
My initial below indicates that I have completed this form and provided accurate information and that I have read the policies and billing procedures and agree to follow them accordingly. I understand that my child will not be allowed to return to the program if any of the above policies are not observed.