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.

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Person Completing Application
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Application Date
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I am a CCPS employeeCheck one
SUMMER CAMP IS FULLNO SPOTS AVAILABLE
Fall Registration- School Year 2021-22
1. Emergency and Identification Information
Child's NameFirst and Last Name
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Nickname
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Child's Home AddressFull Address
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Sex of Child
Birth Date
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Current Grade
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School
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My child was enrolled in Kid Central last school year
Name of Prior Childcare Attended
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Mother's NameFirst and Last Name
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Mother's Home Phone
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Mother's Cell Phone
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Mother's Home AddressFull Address
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Mother's Workplace
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Mother's Business AddressFull Address
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Mother's Work Hours
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Mother's Work Phone
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Father's NameFirst and Last Name
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Father's Home Phone
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Father's Cell Phone
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Father's Home AddressFull Address
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Father's Workplace
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Father's Business AddressFull Address
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Father's Work Hours
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Father's Work Phone
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DESIRED START DATE
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2. Name of 2 persons (other than parents) 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
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Relationship
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AddressFull Address
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Cell Phone
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Home Phone
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2) NameFirst and Last Name
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Relationship
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AddressFull Address
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Cell Phone
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Home Phone
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Other Names of Person(s) permitted to pick up your child and relationship
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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 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! 

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3. Health History
Physician's Name
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Physician's Office Name
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Physician's Phone
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Physician's Address
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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 your child needs medication while in our care, this FORM needs to be completed by parent and doctor, then returned with the proper, labeled medication before the child can begin**



If taking medication, complete the following information:




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 or have your doctor's office fax it to 540-829-2057. It can also be emailed to mrutherford@culpeperhumanservices.org.




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PARENT AGREEMENTSYou MUST Check Each Box
Parent Signature
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Date
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Administrator SignatureType 'X' in box please
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DateType 'X' in box please
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Date Entered Care:Type 'X' in box please
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Date Left Care:Type 'X' in box please
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**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
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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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Person Viewing DocumentationType 'X' in box please
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Date Documentation ViewedType 'X' in box please
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5. Emergency Medical Authorization
Person to be notified when parents cannot be reached in the event of medical emergencyFull Name of somebody other than parents
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Phone #:
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Alternate Phone #:
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Relationship to Child
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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.

 

Parent Signature
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*This form will be kept by Kid Central and will be taken with the child to the hospital or clinic in case of emergency. 


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 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. 


Parent Signature
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7. 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
Parent Signature
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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!

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
Parent Signature
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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.

Parent Handbook AgreementCheck one

Parent Signature
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10. Payment Agreement
My child receives:

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
Parent Signature
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**Childcare Assistance has increased their eligibility to 85% of the state's median income. If you have a child in the household not yet in Kindergarten, you may qualify. Please contact 540-727-1055 to get your application now!**




11. COVID-19 Parent Agreements

In response to the COVID-19 Public Health Emergency, Kid Central has changed some of our protocols in an effort to minimize risk and keep our children, staff and families safe.


Please read and check the circle beside each statement below.

Statement 1Please Check
Statement 2Please Check
Statement 3Please Check
Statement 4Please Check
Statement 5Please Check
Statement 6Please Check
Statement 7Please Check
Statement 8Please Check
I CertifyPlease Check
Parent Signature
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PLEASE DO NOT PAY ANY REGISTRATION OR WEEKLY FEES UNTIL YOU HAVE RECEIVED A PHONE CALL OR ADDITIONAL EMAIL FROM MANAGEMENT CONFIRMING YOUR CHILD HAS A SPOT.

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