Summer Day Camp NEW Campers

NEW CHILD FORM - New children will be placed on a waiting list as priority will go to families enrolled in the 24/25 school year. If space is still available, children will be accepted on a first-come, first-served basis and we must have all required paperwork and applicable fees before they can begin.

Summer Camp Registration 2025 is now FULL

Payments are due 2 weeks in advance. Please do NOT make any payments until you have a confirmed spot. Vendor copays are due by the 15th of each month and you must be swiping your card daily to record attendance.

My Child Will AttendChoose Dates - No Part Time Rates

May 28-May 30 (Payment Due May 16) *CLOSED 26th and 27thJune 2-6 (Payment Due May 23)June 9-13 (Payment Due May 30)June 16- 20 (Payment Due June 6) *CLOSED June 19thJune 23-27 (Payment Due June 14)June 30- July 4 (Payment Due June 20) *CLOSED 4thJuly 7- 11 (Payment Due June 27)July 14-18 (Payment Due July 4)July 21-25 (Payment Due July 11)

Kid Central 2025 Permission to Travel & Swim Form

Child's Namelast name first

START DATE

Has my permission to attend/travel to the following field trips during Kid Central's Summer Day Camp,
May 28-July 25, 2025. Field Trips are subject to change.

-REC CLUB POOL, CULPEPER (all)
-SPLASH PAD, CULPEPER (all)
-PATH CENTER, CULPEPER (all)
-BOUNCE N' CREATE (Grades K-2)
-FUNLAND (Grades 3-8)
-CHUCK-E-CHEESE (Grades K-2)
-URBAN AIR, FREDERICKSBURG (Grades 3-8)
-OLD COUNTRY STORE - ICECREAM (all)
-MESSICK'S FARM (Grades K-2)
-YODER'S PETTING ZOO (PreK)
-COSMETOLOGY CENTER (Grades 7,8)
-SKYZONE MANASSAS (Grades 3-8)
-MT. RUN LAKE PLAYGROUND (PreK)
-MOVIES CHARLOTTESVILLE (all)
-MASSANUTTEN WATER PARK (all)

Field Trip PermissionAlternate care is not provided

My Child May Attend All Trips

Swimming & Sunblock Permission Form

My child has my permission to go swimming at THE CULPEPER REC CLUB in CULPEPER, VA with KID CENTRAL Summer Camp Staff.

Sunblock Permission 

I give Kid Central permission to apply sunscreen to my child(ren) ages 5-8 years of age or to remind my child(ren) ages 9-12 years to apply it to themselves.

Swimming Permissioncheck one

My child MAY get in the poolMy child MAY NOT get in the pool and will sit pool side

My Child is acheck one

Beginner SwimmerIntermediate SwimmerAdvanced Swimmer

Sunscreen Permission

My child has permission to apply sunscreen or have sunscreen applied

1. Emergency and Identification Information

Child's Namelast name first

Nickname

Sex of Childselect

MaleFemale

Birth Date

Rising Grade

School

Best email to reach youa valid email

Mother's Name

Mother's Home Phone

Mother's Cell Phone

Mother's Home Address

0 /

Mother's Business Address

0 /

Mother's Work Phone

Mother's Emaila valid email

Mother's Work Hours

Father's Name

Father's Home Phone

Father's Cell Phone

Father's Home Address

0 /

Father's Business Address

0 /

Father's Work Phone

Father's Emaila valid email

Father's Work Hours

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

Relationship

AddressMust have physical address

0 /

Cell Phone

Namefull name

Relationship

AddressMust have physical address

0 /

Cell Phone

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

0 /

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

0 /

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!

Fileupload

Upload

3. Health History

Physician's Namephysician's full name

Physician's Phone

Does child have any allergies to food or medication?select

YesNo

If yes explain

0 /

Is child currently taking any medication?select

YesNo

If yes complete:

Medication

When given

What is Medication for

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

0 /

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

YesNo

If yes, please explain.

0 /

*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, have it faxed to 540-829-2057, or email it to the enrollment coordinator

PHYSICAL AND IMMUNIZATION RECORDS MUST BE SIGNED OR STAMPED BY PHYSICIAN'S OFFICE

Fileupload

Upload

MEDICAL AGREEMENTS

*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 from the 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 (click link) needs to be completed by parent and doctor and returned with the proper, labeled medication before the child can begin.

Please Check ALL Agreementsselect

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 SignatureI agree

Date

4. Birth Verification Information (We must still see a copy)

Place of Birth

Date of Birth

Birth Certificate Number

Date Issued

Other Form of Proof

Fileupload

Upload

5. Emergency Medical Authorization

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/we will be responsible for payment of medical expenses:

Parent SignatureI agree

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. Bullying will not be tolerated.
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.

Multiple violations of these rules can result in termination from our program.

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

Parent Signaturefull name

7. Photo/Name Release

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 child's 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.

Initializecheck box

I agree with photosI DO NOT AGREE WITH PHOTOS

8. Child Endangerment Release Policy

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

Initializecheck box

I agree to the endangerment policy

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

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.

10. 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 CACFPregulations 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.

CACFP Agreement

I acknowledge the CACFP Agreement

11. Funding Source

Please Check One

I will be paying out of pocket for childcareI receive childcare assistance through VA Department of Social ServicesOther (foster care, adoption funding)

If you do not already have daycare assistance, please do not select that you receive it.

You have to apply for funding by contacting your local Social Services. Funding must be in place before your child can begin.

WE STRONGLY DISCOURAGE BRINGING ELECTRONIC GAMES, TOYS AND ANY VALUABLE ITEMS TO DAYCARE. Phones are not allowed in daycare.

If you choose to allow it, please understand Kid Central is not responsible for lost or stolen items.

Signatureyour full name

Date

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

MEDICAL AGREEMENTS

*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 from ﻿the 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 ﻿(click link)﻿ ﻿needs to be completed by parent and doctor and returned with the proper, labeled medication before the child can begin.

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. Bullying will not be tolerated.﻿﻿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.

﻿

Multiple violations of these rules ﻿can﻿ result in termination from our program.﻿﻿﻿

﻿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

﻿If you do not already have daycare assistance, please do not select that you receive it.﻿﻿

You have to apply for funding by contacting your local Social Services. Funding must be in place before your child can begin.﻿﻿﻿﻿﻿﻿﻿

WE STRONGLY DISCOURAGE BRINGING ELECTRONIC GAMES, TOYS AND ANY VALUABLE ITEMS TO DAYCARE. Phones are not allowed in daycare.﻿﻿

If you choose to allow it, please understand Kid Central is not responsible for lost or stolen items.

**If there is an objection to seeking emergency medical care, a statement should be obtained from the 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 (click link) needs to be completed by parent and doctor and returned with the proper, labeled medication before the child can begin.

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. Bullying will not be tolerated.
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.

Multiple violations of these rules can result in termination from our program.

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”

If you do not already have daycare assistance, please do not select that you receive it.

You have to apply for funding by contacting your local Social Services. Funding must be in place before your child can begin.

WE STRONGLY DISCOURAGE BRINGING ELECTRONIC GAMES, TOYS AND ANY VALUABLE ITEMS TO DAYCARE. Phones are not allowed in daycare.