EmailMe Form - Kids 'N Dance ASP - Daycare Registration

Child's Name *

First Last

Age *

School *

Birthdate *

Grade *

Session Registering for *

June 29th

July 20th

Both 3 week sessions

# of days registering for *

3

4

5

Days of the week Registering for

If 3 or 4 days please let us know which you will be attending

ENROLLMENT & PAYMENT TERMS

- You will be charged in advance for the 3 week registration period/s you are enrolling in. The rate is $73.80/day at 8 hours per day. No refunds or credits.
- No credit is provided for missed days unless we have had to close for a period of time to respond to a report of someone having entered the facility that tested positive for Covid-19. If you opt not to return after re-opening, those days will not be credited
- $1/hour late charge will be charged to your card if you do not pick up your child by 5:00

Session registering for *

I am not applying

I will be applying

I have applied

If you have applied and want to use state funding, you understand there will is additional payment policies to be reviewed with KND

CONTACT INFORMATION

Family Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Primary Parent Contact *

First Last

This person is the parent that should be contacted if there is confusion at pick-up time or about billing concerns.

Primary Parent's Phone Numbers - Please list all possible numbers in the order they should be called. *

Primary Parent's Email *

Secondary Parent Contact

First Last

Secondary Parent's Phone Numbers - Please list all possible numbers in the order they should be called. *

Emergency Contacts: Please list at least one name and number as an emergency contact

Alternate Persons for
Pick-up

This is only for emergencies and they should know that they can not enter the building.

MEDICAL / DENTAL INFORMATION

Medical Information

Doctor's Name:
Address:
Phone:
Insurance Carrier:
Policy Number: *

Dental Information

Dentist's Name:
Address:
Phone:
Insurance Carrier:
Policy Number: *

Permission to seek medical
attention *

Yes

In the event of an emergency, as the parent or authorized representative I give my consent for Kids ‘N Dance staff to use their best judgement to secure proper medical or dental treatment for my child if our physician can not be reached. Care will be prescribed by a duly licensed physician, osteopath or dentist for the above named child. This care may be given under whatever conditions are necessary to preserve the life, limb, or well being of the child. I acknowledge that the costs of any medical treatment provided not covered by medical insurance is our sole responsibility

Permission to administer children's Advil or Ibuprofen when verbal or text permission is received from you regarding the possible need for it (headache or fever) If for a fever, your child will have to be picked up ASAP. *

Yes

No

If permission is given, we will administer the medication according the labeled dosage instructions. If permission is NOT given, we will NOT be able to administer the medication at all.

Allergies/Special Needs

Please list any allergies and actions needed to be taken if exposed to allergen. Use this space to inform us of other medical considerations as well.

Permission to go on 15 minute walking excursion *

Yes - I give my permission for my child to participate

No - I DO NOT give my child permission to participate

All children will be asked to wear a mask. We will stay on residential sidewalks.

Change of Clothes *

Yes - I understand and agree to adhering to this policy

All children 7 or under must have a full set of clothes to change into in the event of an accident. This must be kept in a plastic bag in the child's back-pack.

POLICIES REGARDING REDUCING THE RISK OF COVID-19 TRANSMISSION

Adult Mask Requirement *

Yes - I understand and agree to adhering to this policy

All adults are required to wear a mask upon entering they yard/facility.

Child Mask Requirement *

Yes - I understand and agree to adhering to this policy

Children will be asked to wear a mask when they will not be 6 feet away from each other. If you provide your own, please have it stored in a ziploc plastic bag with your child's name on it.

Social Distancing Requirement *

Yes - I understand and agree to adhering to this policy

Adults will be asked to adhere to staying 6ft apart from others and model the same expectation for their children.

Our Mask or Yours? *

Yes, we will provide a mask

Please provide a mask

Children will be asked to wear a mask when they will not be 6 feet away from each other. If you provide your own, please have it stored in a ziploc plastic bag with your child's name on it.

One adult / family allowed in the facility *

Yes - I understand and agree to adhering to this policy

I understand that only one adult per family is designated to be allowed in the facility and that person should be the drop off person

Drop off & Pick up Policy *

Yes - I understand and agree to adhering to this policy

Upon entering the yard the adult and child must sanitize their hands. If someone other than the regular drop off person is dropping off or picking up you must text to have arrangements made for yard sign-in/pick-up.

Drop off Person *

We prefer the drop off and pick up person to be the same. Only one adult per family is allowed to enter the facility.

Pick Up Person

If not the same as the drop off person, we will send your child out to the yard to meet you. Text Destinique at 510-689-8711 when you arrive.

Drop Off / Sign-In Policy *

Yes - I understand and agree to adhering to this policy

- Upon entering the yard you and your child must sanitize your hands at the gate dispenser
- I understand staff will sign my child in on my behalf.
- I will be required to answer questions regarding contact with others and health of those in the immediate family at sign in. TIME MUST BE ALOTED TO ALLOW FOR THIS TO BE DONE WITHOUT PRESSURE
- I understand that if anyone is sick in the family or if my child shows any sign of sickness they will not be allowed to attend. There is no credit for not attending.
- Temperatures of children attending will be taken and recorded upon sign in
- Children will have to picked up immediately if they show signs of illness mid-day

Commitment to Following Safety Protocols *

Yes - I understand and agree to adhering to this policy

- I understand that if any family members refuse to adhere to our protocols after being reminded, they risk the child being dismissed from the program without advanced notice. Documentation of the reminder provided and policies not followed will be provided. No refunds will be provided if asked to leave the program
- Children will be taught safety guidelines for participating in our program. We understand that they will not always remember but must always be willing to follow directions when reminded. If they seem to have difficulty with following directions and we feel it may potentially compromise the health of others in the program, the family will be notified and if not improved dismissal from the program is possible. Under these circumstances, refunds will not be provided.

OTHER HELPFUL INFORMATION

Social/Emotional Needs

- Are there social/emotional needs we should be aware of?
- What methods are used at home to encourage positive cooperative behavior?

Do you want your child to finish left-over lunch before having KND provided snacks? *

Yes, please have lunch finished first.

No, lunch does not have to be finished first.

Snack is two moderate servings of crunchy foods (goldfish, pretzels, granola bar, etc), one cup of juice, and cheese or fresh fruit.

Survey about Wii game time *

Wii is an infrequent end of day option Scroll down and select a preference about playing/watching time for your child.

ALMOST THERE ......

Release of Liability *

Yes

Checking "Yes" indicates you agree to the following: I voluntarily enroll my child with full knowledge that there is risk of personal injury in activities affiliated with KND (including but not limited to playing on gymnastic and play structure equipment). I agree neither I, my heirs, assigns or legal representatives will sue or make any other claims against Kids N Dance/Onstage, its members or employees for any degree of personal injury or property damage/loss, regardless of cause.

Photo Release *

Yes

No

Checking "Yes" indicates you agree to the following: I grant Kids 'N Dance 'N Theater Arts representatives and employees the right to photograph my child in Afterschool Program activities. In addition, I authorize Kids 'N Dance 'N Theater Arts to copyright, use and publish photographs of my child in marketing materials such as brochures and on Facebook.

Understanding and
Agreement of Policies *

Yes

I acknowledge that I can request a written copy of these Policies.

Access to Parent Handbook *

Yes

I acknowledge that I am aware that the current Parent Handbook is located on the website found here http://kidsndance.com/after-school/fees-registration/

Additional Licensing Paper Work *

Yes

I understand that I will be given 3 additional forms to complete required by Community Care Licensing: Parent Rights, Personal Rights, and Receipt of Licensing Reports. THESE MUST BE SUBMITTED WITHIN ONE WEEK

I understand that Community Care Licensing has the right to interview children or staff without prior consent and has the authority to inspect, audit, and copy child or child care center records during normal business hours. *

Yes

Questions? Comments? Concerns?

Signature *

Clear

Your signature indicates agreement to our registration terms It also signifies consent for items indicated in this completed form.

Printed Name *

First and Last Name of person that completed the form and signed above.