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RETURNING CHILDREN ONLY

Person Completing Application
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Application Date
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Fall Registration- School Year 2022-23
DESIRED START DATE
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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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Name of Prior Childcare AttendedWhich School?
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My child was enrolled in Kid Central last school year
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 (If same as child, write SAME)
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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 (If same as child, write SAME)
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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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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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AddressFull Address
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Relationship
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Cell Phone
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2) NameFirst and Last Name
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AddressFull Address
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Relationship
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Cell 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 and Medical Care Authorization
Does your child have any allergies?select
If yes, explain:
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**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
Medication
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When given
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What is Medication for
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Does child have any medical conditions or diagnoses that we should know about?
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Does your child have an IEP or 504 Plan in place?Select one
If yes to IEP or 504 plan, please explain. If no, put N/A.
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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
Parent SignatureMedical Agreements
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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
6. Other Agreements
Photos/Recognition
Parent Handbook AgreementCheck one
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

7. Funding Source
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 SignatureFor all agreements
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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. CHECK YOUR SPAM FOLDER ALSO FOR AN EMAIL FROM MRUTHERFORD@CULPEPERHUMANSERVICES.ORG

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