ROBERT
AND DOROTHY LUDWIG
KID’S
TIME
2010-2011
REGISTRATION
* Each
form must be accompanied by a NON-REFUNDABLE 10% deposit
* Registration
begins
* Registration
is on a first come, first serve basis
* Registration must occur
by
Child’s
First Name: _____________
Child‘s Last Name: _____________
Please check off the days you would like your child to
attend:
____Monday
____Tuesday
____Wednesday
____Thursday ____Friday
Please register my child for the:
_____Full-day program (pick up prior to
_____Half-day program (pick up prior to
Please indicate which Kid’s Time site you would like your
child to attend:
___
Child's
Birthday _____/_____/_____ Gender ______Male _____Female
Grade (as
of September 2010) _________
School ____________________________
Street
Address: ________________________________________________________
City,
State, Zip: ________________________________________________________
Home Phone: _____________________________________________
Parent’s
Name: ______________________
Occupation: _______________________
Work #:
______________________ Cell #:
_______________________
Parent’s
Name: ______________________
Occupation: _______________________
Work #:
______________________ Cell #:
_______________________
E-mail
Address: _____________________________________________________________
Are you
interested in serving on a Kid’s Time program committee? Yes ____
No ____
The Kid’s
Time program provides services to all children regardless of sex, race, creed,
color, religion, handicap or national origin.
I understand and agree to the following:
1. I will make all tuition payments in a timely
fashion as specified: Half the yearly
tuition is due in September. The
remainder is due in January. Alternate
payment plans such as monthly payments are also acceptable. There are no reductions or credits for
illnesses, vacations, or school closings.
2. If my child will not be attending Kid’s
Time on her/his regular day, I will call the JCC prior to her/his usual arrival
time. Failure to do so may result in my
child being removed from the program.
3. The
Center will provide me with a parent manual detailing Kid’s Time policies.
4. The Kid’s Time program schedule corresponds
to the
5. If a behavior problem arises, I understand
that attempts will be made between the staff, the parent, and the child to
rectify the situation. If, after these
attempts, the situation continues, I realize that my child may, at the sole
discretion of the Kid’s Time program; be temporarily or permanently removed
from the program. A discipline policy
will be provided to families in August.
6. I must
notify the School-Age Director in writing, if I plan to withdraw my child
before the end of the school year. If I notify the JCC in writing, I am
responsible for all the time my child attended, plus an additional 10% of the
yearly fee. If I remove my child and
fail to notify the
7. Scheduled Niskayuna
8. I will remit the 10% deposit upon
enrollment, which is non-refundable, but is applicable towards the last
month of tuition.
9. I
understand that there will be a $26 service charge for any checks returned to
the JCC.
10. I understand that if I pick my
child up late, I will incur the following fees:
11. There will be a $10 administrative
fee for any changes that you make to your child’s schedule.
12. I
understand that the JCC is not responsible for any items lost while at the
Kid’s Time program.
13. A copy
of this form is available upon request.
I have read
and understand this registration form in full and agree to all terms.
________________________ _________________________
______________
Name of Parent or Legal
Guardian Signature of Parent or Legal
Guardian Date
(Please Print)
2010-2011 KID’S TIME
CHILD INFORMATION SHEET
CHILD'S NAME
(Last) ______________________________(First)
______________________________
GRADE
(Entering) ___________ BIRTH DATE ____/____/____ AGE_______ GE
HOME ADDRESS: STREET_______________________________________________________
CITY_________________________________ STATE
_______ ZIP__________________
HOME PHONE_______________________ SCHOOL
ATTENDING_______________________________
CHILD LIVES WITH: _____Both Parents _____Mother ______Father
Other (PLEASE EXPLAIN) ____________________________________________________________________________________
Parent’s (or guardian) Name: ______________________________________________________________
Occupation
_____________________________________________________________________________
Business #
_________________________________ Cell #______________________________________
Parent’s (or guardian) Name:
______________________________________________________________
Occupation
_____________________________________________________________________________
Business #
_________________________________ Cell #______________________________________
STARTING WITH YOURSELF, PLEASE LIST IN ORDER ALL PEOPLE TO CONTACT IN CASE
OF EMERGENCY:
1)___________________________/__________________/____________________/_______________/______________
Name Work Phone Home
Phone Cell Phone Relationship to child
2)___________________________/__________________/____________________/_______________/______________
Name Work Phone Home
Phone Cell Phone Relationship to child
3)___________________________/__________________/____________________/_______________/______________
Name Work Phone Home
Phone Cell Phone Relationship to child
4)___________________________/__________________/____________________/_______________/______________
Name Work
Phone Home
Phone Cell Phone Relationship to child
5)___________________________/__________________/____________________/_______________/______________
Name Work Phone Home
Phone Cell Phone Relationship to child
ONLY PEOPLE LISTED ABOVE MAY PICK UP YOUR CHILD
MEDICAL
CONCERNS (ALLERGIES, VISION/HEARING IMPAIRMENTS, MOTOR SKILLS, ETC.):
_____________________________________________________________________________________________________________________________________________________________________
IS
YOUR CHILD ON ANY MEDICATION? _____________
PLEASE SPECIFY________________________
____________________________________________________________________________________________________________________________________________________________________________________
NAME
OF ANY MEDICATION TO BE ADMINISTERED WHEN AT CRAIG KID’S TIME (ADDITONAL APPROPRIATE
__________________________________________________________________________________________
WHEN/AMOUNT:
________________________________________________________________________________
PLEASE
LIST ANY SOCIAL CONCERNS: (DEATH,
DIVORCE, SEPARATION...) __________________________________________________________________________________________
__________________________________________________________________________________________
PLEASE LIST YOUR CHILD'S INTERESTS
AND HOBBIES:
__________________________________________________________________________________________________________________________________________________________________________________
PLEASE DESCRIBE ANY
PSYCHOLOGICAL CONDITIONS OR FEARS:
_________________________________________________________________________________________
_________________________________________________________________________________________
PLEASE PROVIDE ANY OTHER
INFORMATION THAT WILL HELP US CARE FOR YOUR CHILD:
__________________________________________________________________________________________________________________________________________________________________________________
NAME OF PHYSI
NAME OF DENTIST_________________________________ ________
WHAT WAS YOUR PREVIOUS CHILD
CARE ARRANGEMENT (IF NOT KID’S TIME)
_________________________________________________________________________________________
I AGREE THAT IN CASE OF
ACCIDENT OR INJURY, EMERGENCY MEDICAL CARE MAY BE GIVEN IN THE EVENT THAT I OR,
PERSON(S) DESIGNATED, CANNOT BE REACHED.
I WILL PROVIDE ALL
___________________________ _____________________________
____________
Name of Parent or Legal
Guardian Signature of Parent or Legal
Guardian Date
(Please Print)