Fall Registration

Dear Parents and Guardians,

Welcome to Culpeper County Child Care’s Preschool and Kid Central! It is a pleasure to extend our services to you and your child(ren). We trust that our relationship will be a positive one.

We feel strongly that open communication between parents and our program staff is essential to fully meet your child’s needs. Please read your Parent Handbook very carefully, as it is your guideline for our policies. If you have any questions, please do not hesitate to contact us for clarification.

On behalf of all Kid Central, thank you for entrusting your child(ren) to our care. Download the application below or fill out our online application.

Thank you!

KC Parent Information PLEASE REMEMBER:

To sign your child(ren) in every morning

To sign your child(ren) out every morning

Payment must be paid weekly

Your account may not exceed $100.00 depending on individual pay cycles

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1. Emergency and Identification Information
Child's Namelast name first
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Nickname
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Sex of Childselect
Birth Date
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Current Grade
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School
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Prior Childcare ProgramIf applicable
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Mother's Name
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Mother's Home Phone
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Mother's Cell Phone
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Mother's Home Address
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Mother's Business Address
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Mother's Work Phone
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Mother's Work Hours
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Father's Name
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Father's Home Phone
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Father's Cell Phone
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Father's Home Address
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Father's Business Address
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Father's Work Phone
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Father's Work Hours
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2. Name of 2 persons authorized to take the child from the facility. YOUR CHILD WILL NOT BE PERMITTED TO LEAVE WITH ANY PERSON(S) NOT PREVIOUSLY APPROVED BY PARENT OR GUARDIAN. NO EXCEPTIONS!!
Namefull name
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Relationship
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Address
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Cell Phone
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Home Phone
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Namefull name
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Relationship
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Address
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Cell Phone
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Home Phone
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Date Daycare is to Begin
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Other Names of Person(s) permitted to pick up your child
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Names of Person(s) NOT ALLOWED to pick up your child
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Appropriate paperwork such as custody papers must be attached if a parent is not allowed to pick-up a child. We cannot stop a parent from picking up their own child unless outlined by a court order! 

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3. Health History
Physician's Namephysician's full name
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Physician's Phone
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Does child have any allergies to food or medication?select
If yes explain
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Is child currently taking any medication?select

If yes complete:

Medication
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When given
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What is Medication for
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Does child have any medical condition that may prevent him/her from participating in physical activities?
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Does your child have an IEP or 504 Plan in place?select

*A COPY OF YOUR CHILD’S IMMUNIZATIONS AND RECENT PHYSICAL (BOTH SIGNED OR STAMPED BY DR) MUST BE RECEIVED BEFORE CARE CAN BEGIN.

You can upload that here if you have it.

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Agreements

  1. The child daycare center agrees to notify the parent/guardian whenever the child becomes ill and the parent/guardian will arrange to have the child picked up as soon as possible, if so requested by the center.
  2. The parent/ guardian authorizes the child daycare center to obtain immediate medical care if any emergency occurs when parent/guardian cannot be located immediately.
  3. I agree to inform Culpeper County Child Care within 24 hours or the next business day after my child or any member of our immediate household has developed any reportable communicable disease, as defined by the State Board of Health, except for life threatening diseases which will be reported immediately.

*If your child becomes ill or injured you will be notified and must arrange to have your ill child picked up immediately. Illnesses include, but are not limited to, fever, diarrhea, vomiting, rashes (unless being treated by a doctor), and upset stomach.

**If there is an objection to seeking emergency medical care, a statement should be obtained frombthe parents or guardian that states their objection and the reason for their objection.

***If a child needs medication while in our care, the following form needs to be completed by parent and doctor and returned with the proper, labeled medication before the child can begin.

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4. Birth Verification Information
Place of Birth
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Date of Birth
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Birth Certificate Number
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Date Issued
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Other Form of Proof
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*A report card can be turned in as a form of a birth record


5. Emergency Medical Authorization
Name of Childfull name
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Name of Parent/Guardianyour full name
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Home Address
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Home Phone:
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Work Phone:
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Person to be notified when parent cannot be reached in the event of medical emergencyfull name
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Phone:
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Relationship to Child
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The parent/guardian authorizes the Culpeper County Child Care program to obtain immediate medical care and consents to the hospitalization of the performance of necessary diagnostic test upon the use of surgery on, and/or the administration of medication to his/her child or ward if an emergency occurs when he/she cannot be located immediately. It is also understood that this agreement covers only those situations which are true emergencies and only when the parent/guardian cannot be reached. Otherwise, the parent/guardian expects to be notified immediately.


I/we will be responsible for payment of medical expenses: 

 

Namefull name
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Medical treatment costs are covered by
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Insurance Number
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Name of Company
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Physician's Namephysician's full name
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Physician's Phone
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*This form will be kept by Culpeper County Child Care and will be taken with the child to the hospital or clinic in case of emergency. 

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6. Kid Central Code of Conduct Agreement

Kid Central requires all children to follow the Code of Conduct, which is as follows: 

  • Respect the rights and property of others 
  • Cooperate by observing the rules and refraining from foul language, disrespectful back talk, and physical contact with another student or staff member 
  • Take advantage of all the enriching opportunities presented 

Should any of these rules be broken, at anytime, parents will receive a written documentation (Code of Conduct Report) to inform of their child’s behavior, consequences, and actions taken. 

Parents are asked to sign the Code of Conduct Report to verify that they have read the report, not necessarily agreeing with it. 

I (Name)full name
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agree to follow the above conduct agreement. 

Student Signaturefull name
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I, the parent of the above, understand the above rules are expected to be followed by my child(ren). 

Parent Signaturefull name
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7. Photo/Name Release

Dear Parents: 

From time to time, Culpeper County Kid Central would like to recognize students for special accomplishments by putting their names and/or picture in the newspaper or on Facebook. This letter is for your approval for using your child name or picture in the newspaper or Facebook, on television, or video when the occasion presents itself. Please sign and return this form to the school if you have no objections.


I hereby give permission for my son/daughter. 

Child's Namefull name
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Name and/or pictures to be used for special accomplishment or projects during the summer and school year. I understand that this is a positive way of giving my child recognition. 

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8. Child Endangerment Release Policy

ATTENTION PARENTS: KID CENTRAL HAS THE RIGHT TO REFUSE THE DISMISSAL OF ANY CHILD TO A PARENT SUSPECTED OF BEING UNDER THE INFLUENCE OF DRUGS OR ALCOHOL!

Culpeper County Child Care’s program will follow these procedures in releasing children from the centers  If the staff suspects that the adult picking up the child is under the influence of alcohol, drugs, or misused medication: 

Step one: Staff will review the signed “Child Endangerment Release Policy”

Step Two: If the adult insists on taking the child from the center, a staff member will immediately call in a “Child Abuse Report” to Child Protective Services and/or the police department. 

Step Three: A staff member will then call their supervisor and / or the administrator to inform them of the incident. 

Step Four: A staff member will document the incident on the “Child Abuse Report” Form and send it to the Program Director. 


I HAVE READ AND UNDERSTOOD THE ABOVE CHILD ENDANGERMENT POLICY 

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9. Parent Handbook Agreement

Kid Central’s Parent Handbook can be found on our website here.

It is your responsibility to review this Handbook regarding Kid Central’s mission, policies, and procedures.

Please Check Oneselect

In addition, I understand that: 

KID CENTRAL IS NOT RESPONSIBLE FOR LOST OR STOLEN ITEMS. WE STRONGLY DISCOURAGE BRINGING ELECTRONIC GAMES AND OTHER ITEMS TO DAYCARE 


Signatureyour full name
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Date
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10. Payment Agreement
Child's Name
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School
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Mother's Name
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SSNlast 4 digits
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Mother's Address
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Home Phone
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Work Phone
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Cell Phone
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Father's Name
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SSNlast 4 digits
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Father's Address
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Home Phone
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Work Phone
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Cell Phone
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I agree to make my payments on time and I understand that if I get behind on payments that late fees will be added and my child can lose his/her childcare slot. I understand that if the unpaid balance is not paid in full within 30 days, legal action can be taken.

Mother's Signatureyour full name
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Father's Signatureyour full name
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Date
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