KID'S CLUB SCHOOL-AGED CHILD APPLICATION
NAME OF PROGRAM
SITE__________________________________________________________
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Child's full
name_____________________________________________________________
Date of
admission_____________________________________________________________
Child's birth date__________What does child like to be
called_________________
Grade in
school______Teacher__________________________________________________
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Parent Information:
Name of mother_______________________________________________________________
Address________________________________Home phone____________________________
Employer/address___________________________Work phone________________________
Name of father_______________________________________________________________
Address________________________________Home phone____________________________
Employer/address___________________________Work phone________________________
If parents are divorced, which parent has custody of child?__________________
(For child's safety, list others to whom child may be released:
__________________________________________________________________
N0TE: The child will not be released to anyone not listed on this form
without written and verbal confirmation from the custodial parent(s).
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Emergency Information:
Name of person, other than the program director, authorized to act for the
parent in case of an
emergency________________________________________________
Address of emergency
contact__________________________________________
Home phone__________________Work
phone________________________________
Physician_________________Phone_________Address______________________________
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Child's hobbies or special
interests:_________________________________________
Please list any information regarding allergies or special medications your
child may be
receiving________________________________________________________
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Authorization:
I authorize the child care personnel to arrange emergency medical care for
my
child. The Wilson County Board of Education provides liability insurance
for
its programs. I understand that I must provide my own accident insurance
should I desire this for my child. I agree to hold the school, its staff,
Kid's Club, board of education employees, and school board members free from
liability in this program.
_____________________________________________________________________________
Parent's signature
Child enrolled in the following sessions:___Mon.___Tue.___Wed.___Thur.___Fri.
___daily___weekly (you will be billed according to the rate you choose)
THIS FORM MUST BE RETURNED BEFORE YOUR CHILD IS ALLOWED TO ATTEND THE KID'S
CLUB PROGRAM.
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Child's
Name______________________________________Date________________________
I have received and read the summer regulations and will abide by the
policies____yes,____no.
I am responsible for paying all days even if my child does not attend
(unless
daily rates, vacation or illness guidelines are met). I will pay each week
in advanace of services rendered.
I give permission for my child to go on field trips . I understand that a
fee may be charged for some of these trips.
It is my responsibility to check the schedule for the next day's activities
to see what my child will need.
I will pick up my child by 6:00 P. M. I understand that a late fee of $1.00
per minute will be assessed by 6:00 P. M.
I will keep my child home when he/she is sick.
I understand that the activity fee pays for crafts, consumable goods,
program
materials and supplies, bus charges, field trips, resourses, etc.
Furthermore, I understand that this fee is non-refundable in all
circumstances.
I give permission for my child to watch movies that are deemed appropriate
by
the KID'S CLUB site director unless I specify otherwise.
My child knows how to swim well___yes,___no.
My child may use the diving board___yes___no.
(only if they are able to swim the width of the pool unassisted)
I HAVE READ THE CONSEQUENCES FOR INAPPROPRIATE BEHAVIOR. I UNDERSTAND THAT
MORE THAN ONE CONSEQUENCE MAY OCCUR AT A TIME AND COULD RESULT IN REMOVAL OF
MY CHILD FROM THE PROGRAM.
Signature of
Parent/Guardian________________________Date______________________
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RATES FOR FALL PROGRAMS
One Child Two Children Three Children
After School $50 $75 $95
Before School $10 $20 $30
Before and After School $60 $95 $125
At the time of enrollment you may choose either a daily rate or a weekly
rate. This is the rate at which you will be charged during the year unless
you notify the dite director in writing of any changes.
Morning:--$5.00 Afternoon--$12.00 Both--$15.00
