Online Registration

Dear Parents and Guardians,

Welcome to Culpeper Human Services 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.

Thank you!

KC Parent Information

PLEASE REMEMBER:

To sign your child(ren) in every morning using your thumbprint

To sign your child(ren) out every afternoon using your thumbprint

Swipe your card daily if you receive childcare assistance

Your account may not exceed $150.00 depending on individual pay cycles

The long-standing collaboration between Kid Central and the Culpeper County Public Schools (CCPS) has served the working parents of public school students for 30 years.

Kid Central operates a before and after school program at each elementary school and middle schools (aftercare only) for children enrolled in person.

Your child’s registration is not complete until Kid Central’s program administration confirms he/she has a spot, receives all necessary paperwork, and receives the registration fee or proven funding source.

SEE RATE SHEET HERE

WE ARE ONLY ACCEPTING REGISTRATIONS FOR ALREADY ENROLLED EARLY HEADSTART STUDENTS

We have no spots remaining at the elementary schools for the 23/24 school year.

Your child will be placed on a waiting list.

If you are signing up after 9/15/23, we cannot accept anymore children for all day daycares when school is closed. We are full for the school year.

Person Completing Application

Application Date

Registration- School Year 2023-24

My child will need Before Care for the School YearMy child will need After Care for the School YearMy child will need All Day Daycare when school is closed (ADD sign ups go out 2 weeks in advance of the closing. Checking this box does not guarantee a spot in ADD.)

DESIRED START DATE

1. Emergency and Identification Information (ONE CHILD PER FORM)

Child's NameFirst and Last Name

Nickname

Child's Home AddressFull Address

Sex of Child

MaleFemale

Birth Date

Current Grade

School

My child was enrolled in Kid Central last school year

YesNo

Name of Prior Childcare Attended

Best email address to reach youThis will be used to confirm registration (check your spam)

Guardian #1's NameFirst and Last Name

Relationship to Child

Primary Phone #

Secondary Phone #

Home AddressFull Address (If same as child, write SAME)

0 /

Workplace

Business AddressFull Address

0 /

Work Hours

Work Phone

Email addressif different than above

Guardian #2's NameFirst and Last Name

Relationship to Child

Primary Phone #

Secondary Phone #

Home AddressFull Address (If same as child, write SAME)

0 /

Workplace

Business AddressFull Address

0 /

Work Hours

Work Phone

Email addressif different than above

2. Name of 2 emergency contacts (NOT LISTED ABOVE) 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!!

1) NameFirst and Last Name

AddressFull Address

0 /

Relationship to child

Cell Phone

2) NameFirst and Last Name

AddressFull Address

0 /

Relationship to child

Cell Phone

Other Names of Person(s) permitted to pick up your child and relationship

0 /

Names of Person(s) NOT ALLOWED to pick up your child

0 /

Appropriate paperwork such as custody papers must be attached or provided in person if a biological parent is not allowed to pick-up a child. We cannot stop him/her from picking up unless outlined by a court order!

Fileupload

Upload

3. Health History and Medical Care Authorization

Physician's Name

Physician's Office Name

Physician's Phone

Physician's Address

Does child have any medical conditions or restrictions that may prevent him/her from participating in physical activities?

0 /

Does child have any allergies to food or medication?select

YesNo

If yes, explain:

0 /

For children with asthma or allergies to foods, we will need an Allergy and Anaphylaxis Action Plan or VA Asthma Action plan completed by the doctor. Any rescue meds will need to have these plans and a MAT form completed by the doctor and guardian.

Is child currently taking any medication?Select

Yes and my child will need medication administered while in daycareYes but administered at homeNo

What is Medication for

Medication

When givenif we are to administer

**If your child needs medication while in our care, this Medical Authorization (MAT) FORM needs to be completed by parent and doctor, then returned with the proper, labeled medication before the child can begin**

Does your child have an IEP or 504 Plan in place?Select one

YesNo

If yes to IEP or 504 plan, please explain. If no, put N/A.

0 /

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

You can upload that here if you have it or have your doctor's office fax it to 540-829-2057. It can also be emailed to mwarner@culpeperhumanservices.org. We are not affiliated with the school system and cannot share their files.

Fileupload

Upload

MEDICAL AGREEMENTSYou MUST Check Each Box

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 Kid Central 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.

Parent SignatureMedical Agreements

Date

The parent/guardian authorizes the Kid Central 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 understand I will be responsible for payment of medical expenses.

**If there is an objection to seeking emergency medical care, a statement should be obtained from the parent(s) or guardian(s) that states the objection and the reason for the objection.

4. Birth Verification Information (We MUST still see the proof of birth).

Place of Birth

Date of Birth

Birth Certificate Number

Date Issued

Other Form of Proof

Fileupload

Upload

5. 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 understand the above rules are expected to be followed by my child.

I ALSO UNDERSTAND KID CENTRAL IS NOT RESPONSIBLE FOR LOST OR STOLEN ITEMS.

I agree to the Code of Conduct Agreement

6. Photo/Name Release

From time to time, Culpeper's Kid Central would like to recognize students for special accomplishments by putting their names and/or pictures in the newspaper or on Facebook.

I give permission for my son/daughter's name and/or pictures to be used for special accomplishments or projects during the summer and school year. I understand that this is a positive way of giving my child recognition.

Photos/Recognition

I agreeI DO NOT AGREE

7. 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!

Kid Central’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

Child Endangerment Release Policy

I agree

8. 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.

Parent Handbook AgreementCheck one

I understand that it is my responsibility to review Kid Central’s Handbook.I do not have Internet access and need a paper copy of the Handbook.

9. CACFP Agreement

This institution participates in the Child and Adult Care Food Program (CACFP) and receives Federal reimbursement to provide nutritious meals for children. Federal CACFP regulations require all parents/guardians to complete and sign a separate Annual Enrollment Form for each child when enrolling their child(ren) with this provider, and every 12 months thereafter. By registering for Kid Central I understand I am enrolling in the CACFP. My Child will be attending M-F between the hours of 6:30 am -6:30 pm receiving Breakfast, AM Snacks, Lunch and or PM Snacks as appropriate. This institution is an equal opportunity employer.

I understand

I agree for my child to be enrolled in the CACFP

10. Payment Agreement

You must already be a recipient of childcare assistance to check the childcare assistance circle. If you are not and are interested in receiving childcare assistance, contact 540-727-1055 for an application.

Please check 'Selfpay' until you are approved.

My child receives:

Child care assistance through DSSFoster care/Adoption fundingNot applicable - Selfpay

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.

If receiving childcare assistance, I understand that I MUST swipe my card each day my child is in attendance to guarantee payment.

Payment/Childcare Assistance Agreement

I agree

Parent Signature

PLEASE DO NOT PAY ANY REGISTRATION OR WEEKLY FEES UNTIL YOU HAVE RECEIVED A PHONE CALL OR ADDITIONAL EMAIL FROM
MWARNER@CULPEPERHUMANSERVICES.ORG
CONFIRMING YOUR CHILD HAS A SPOT. PLEASE BE SURE TO CHECK YOUR SPAM FOLDER.

Online Registration

KC Parent Information

PLEASE REMEMBER:

If you are signing up after 9/15/23, we cannot accept anymore children for all day daycares when school is closed. We are full for the school year.﻿﻿

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

You can upload that here if you have it or have your doctor's office fax it to 540-829-2057. It can also be emailed to mwarner@culpeperhumanservices.org. We are not affiliated with the school system and cannot share their files.﻿

I understand the﻿ above rules are expected to be followed by my child.

I ALSO UNDERSTAND KID CENTR﻿AL IS NOT RESPONSIBLE FOR LOST OR STOLEN ITEMS.

​

You must already be a recipient of childcare assistance to check the childcare assistance circle. If you are not and are interested in receiving childcare assistance, contact 540-727-1055 for an application.

Please check 'Selfpay' until you are approved.

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.

﻿If receiving childcare assistance, I understand that I MUST swipe my card each day my child is in attendance to guarantee payment.

If you are signing up after 9/15/23, we cannot accept anymore children for all day daycares when school is closed. We are full for the school year.

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

You can upload that here if you have it or have your doctor's office fax it to 540-829-2057. It can also be emailed to mwarner@culpeperhumanservices.org. We are not affiliated with the school system and cannot share their files.

I understand the above rules are expected to be followed by my child.

I ALSO UNDERSTAND KID CENTRAL IS NOT RESPONSIBLE FOR LOST OR STOLEN ITEMS.

If receiving childcare assistance, I understand that I MUST swipe my card each day my child is in attendance to guarantee payment.