RETURNING CHILDREN ONLY

Person Completing Application

Application Date

DESIRED START DATE

PLEASE SELECT

My child needs before school careMy child needs after school careMy child will need All Day Daycare when school is closed (I understand there are separate sign ups for ADD days)

1. Emergency and Identification Information

Child's NameFirst and Last Name

Birth Date

Child's Home AddressFull Address

Sex of Child

MaleFemale

Nickname

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

Guardian #1's NameFirst and Last Name

Relationship to Child

Primary Phone Number

Secondary Phone Number

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

0 /

Workplace

Business AddressFull Address

0 /

Work Hours

Work Phone

Emaila valid email

Guardian #2's NameFirst and Last Name

Relationship to Child

Primary Phone Number

Secondary Phone Number

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

0 /

Workplace

Business AddressFull Address

0 /

Work Hours

Work Phone

Emaila valid email

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!

2. ANY CHANGES SINCE LAST REGISTRATION?

List any changes in medical history, phone numbers, addresses, pick up people, custody, etc. If no changes, put n/a.

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:

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!

1) NameFirst and Last Name

AddressFull Address

0 /

Relationship

Cell Phone

2) NameFirst and Last Name

AddressFull Address

0 /

Relationship

Cell Phone

Fileupload

Upload

3. Any Changes in Medical History Since Last School Year?

Does your child have any allergies, medical conditions, or restrictions?select

YesNo

If yes, explain, otherwise put n/a:

0 /

Is child currently taking any medication that we will need to administer?Select

YesNo

Medication

When given

What is Medication for

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 mwarner@culpeperhumanservices.org

3. 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 SignatureI AGREE

4. 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

5. All Other Information is the Same

Do you agree?

I 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.

Child Endangerment AgreementCheck one

I agree

6. Funding Source and Payment Agreement

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 mwarner﻿@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.

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

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