RETURNING CHILDREN ONLY

Person Completing Application

Application Date

Fall Registration- School Year 2022-23

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

Child's NameFirst and Last Name

Nickname

Child's Home AddressFull Address

Sex of Child

MaleFemale

Birth Date

Current Grade

School

Name of Prior Childcare AttendedWhich School?

My child was enrolled in Kid Central last school year

YesNo

Best email to reach youa valid email

Mother's NameFirst and Last Name

Mother's Home Phone

Mother's Cell Phone

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

0 /

Mother's Workplace

Mother's Business AddressFull Address

0 /

Mother's Work Hours

Mother's Work Phone

Mother's Emaila valid email

Father's NameFirst and Last Name

Father's Home Phone

Father's Cell Phone

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

0 /

Father's Workplace

Father's Business AddressFull Address

0 /

Father's Work Hours

Father's Work Phone

Father's Emaila valid email

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

AddressFull Address

0 /

Relationship

Cell Phone

2) NameFirst and Last Name

AddressFull Address

0 /

Relationship

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

Does your child have any allergies?select

YesNo

If yes, explain:

0 /

**If your child needs medication while in our care, please use this FORM . It 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:

Is child currently taking any medication?Select

YesNo

Medication

When given

What is Medication for

Does child have any medical conditions or diagnoses that we should know about?

0 /

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 /

WE MUST HAVE A COPY OF YOUR CHILD'S MOST RECENT PHYSICAL & IMMUNIZATION RECORDS (Signed/stamped by doctor's office) BEFORE YOUR CHILD CAN BEGIN. EVEN IF YOUR CHILD HAS ATTENDED BEFORE, WE MAY REQUEST THESE RECORDS AGAIN.

Please have the doctor's office fax to 540-829-2057 or you can email them to mrutherford@culpeperhumanservices.org

4. Medical Agreements

PARENT 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

5. 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 with the CACFP enrollment

6. Other Agreements

Photos/Recognition

I agree I DO NOT AGREE

Parent Handbook AgreementCheck one

I understand that it is my responsibility to review Kid Central’s Handbook.I need a paper copy of the Handbook.

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!

Child Endangerment AgreementCheck one

I agree

7. Funding Source

My Child Receives:

Child care assistance through DSSFoster care/Adoption fundingN/A - 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 SignatureFor all agreements

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 ALSO.

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!

WE MUST HAVE A COPY OF YOUR CHILD'S MOST RECENT PHYSICAL & IMMUNIZATION RECORDS (Signed/stamped by doctor's office) BEFORE YOUR CHILD CAN BEGIN. EVEN IF YOUR CHILD HAS ATTENDED BEFORE, WE MAY REQUEST THESE RECORDS AGAIN.﻿﻿﻿﻿﻿﻿

Please have the doctor's office fax to 540-829-2057 or you can email them to mrutherford@culpeperhumanservices.org﻿﻿

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.

WE MUST HAVE A COPY OF YOUR CHILD'S MOST RECENT PHYSICAL & IMMUNIZATION RECORDS (Signed/stamped by doctor's office) BEFORE YOUR CHILD CAN BEGIN. EVEN IF YOUR CHILD HAS ATTENDED BEFORE, WE MAY REQUEST THESE RECORDS AGAIN.

Please have the doctor's office fax to 540-829-2057 or you can email them to mrutherford@culpeperhumanservices.org

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