Kids Care  

After School Program Registration
Fall 2009
 
Name____________________________

 

 Birthdate: _____________________

 

 Grade:__________

 
Mother __________________________________________________  
Address: ________________________________________________ Home Phone:_______________
Business, Mother _________________________________________ Work Phone: _______________
  Cell Phone:  _______________
Father __________________________________________________ Home Phone: ______________
Address: ________________________________________________ Work Phone: _______________
Business, Father _________________________________________ Cell Phone:  _______________
   
Child lives with:    Mother _____      Father _____      Both _____  

Person(s) other than parents who may remove the child from the program:
Name: ________________________ Address: _________________________ Phone: ____________
Name: ________________________ Address: _________________________ Phone: ____________
Name: ________________________

 

 Address: _________________________

 

 Phone: ____________

 
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I give my child ______________________________________________ permission to participate fully in the KIDS CARE Program.  I have received and read the Kids Care Handbook.  I understand that the weekly tuition is due prior to the week of participation.   After one returned check, KIDS CARE will only accept cash, cashier's check or money order as payment.  Students who are picked up after hours will be charged a late fee of $5.00 for each 15 minutes after 6:00 PM. 

Signature: ________________________________________________   Date: ________________________

     

KIDS CARE After School Enrichment Program

AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT
 


If my child ________________________________ should become ill or injured at San Carlos Park Elementary School, I understand that the facility will (1) contact me immediately and (2) contact the person(s) I have designated if I cannot be reached.  Should the facility be unable to reach me and/or the person(s) designated, they are authorized to contact my child's physician and/or arrange for immediate emergency treatment.  The physician and/or medical facility is authorized to administer emergency medical treatment necessary to ensure the health and safety of my child.  I will accept responsibility for payment of medical services rendered.
  Signature _________________________
Relationship _______________________
Date _____________________________

 		  
Medical Alert Information (i.e., allergies, medical and/or handicapping conditions: )
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Preferred Physician: ______________________________________________________________________
Address: _____________________________________________    Phone: __________________________
Preferred Hospital: ________________________________________________________________________
HEALTH INSURANCE: ____________________________________________________________________
Policy Number: _________________________________________  Expiration Date: __________________
Company Name:__________________________________________________________________________