EmailMe Form - DAY CARE REGISTRATION FOR OUSD STRIKE

Child *

First Last

Age *

Grade *

School *

DAYS REGISTERING FOR CARE:

Payment for preregistered days is required. Refunds will be made if the strike ends, otherwise no refunds are provided.

I understand no refunds will be issued unless the strike ends and school is resuming on your registered days. *

Yes

Wish we could be more flexible, but adding this care with so many variable schedules is logistically challenging.

3/4 Monday FULL *

NO

3/5 Tuesday FULL *

NO

3/6 Wednesday FULL *

NO

NOTE THE EARLIER END TIME

3/7 Thursday FULL *

NO

3/8 Friday FULL *

NO

YES, WE WILL BE OFFERING ADDITIONAL DAYS BEYOND 3/8 IF NEEDED

Email notices will go out buy the Wednesday before FOR THE FOLLOWING WEEK. We will continue this on a week by week basis.

Is your child currently enrolled in our After School Program *

Yes - Only STARRED fields are required

No- Complete ALL fields below

Primary Emergency Contact
(Parent/Guardian) *

First Last

Phone 1 *

### - ### - ####

Phone 2

### - ### - ####

Email

Secondary Emergency Contact
(Parent/Guardian)

First Last

Phone 1

### - ### - ####

Phone 2

### - ### - ####

Names of persons authorized to take child from the facility:

Name/s

Relationship

*Child will not be allowed to leave without authorization from parent

I understand that if I am late to pick up my child, my credit card on file will be charged $1/min. *

Yes

HEALTH INFORMATION

Permission Given to
Seek Medical Attention

Yes

As the parent or authorized representative, I hereby give consent to Kids N Dance N Theater Arts to obtain Medical or Dental care prescribed by a duly licensed physician (MD) or dentist (DDS). This care may be given under whatever conditions are necessary to preserve the life, limb, or well being of the child named above.

I am aware that families are asked to pack lunches and snacks free of peanuts and tree nuts including those that may have traces of nuts. *

Yes

We provide one nut free snack. If your child has severe allergies we recommend you pack your own snack.

If children inadvertently bring nut products to camp, they will be asked to eat one of our nut free snacks instead. We apologize for the inconvenience and appreciate your support in helping create a safe environment for all campers. If your child has a nut allergy, it is still important that you notify staff and inform us whether an epi pen is to be supplied.

List any pertinent health concerns:
- allergies
- medication
- diabetes, asthma, etc.
- NOTIFY OF EPI PEN NEEDS

All medications must be provided to the staff and administering directions must be detailed here. PLEASE CONFIRM NOTIFICATION AT SIGN IN

SOME LOGISTICS

Permission to transport *

Yes

I give permission for my child to be transported to and from Roberts Park from Kids N Dance N Theater Arts

Transportation to Crocker at 3:00/1:30 *

OUR CHILD Needs Transportation

OUR CHILD Does NOT need Transportation

Our driver can bring your child to AT at the end of their day with us

Booster Seat Needed *

Yes

No

For transportation in the van

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 any activity affiliated with KND. 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, property damage/loss, regardless of cause.

Is there anything else we might need to know about your child?

We want your child to have the best possible experience at camp. Is there anything we should know about your child that will help us know what their needs are?

Signature of parent/guardian who completed this form. You will next be directed to make your payment.

Clear

Use your mouse or touch pad to sign electronically

I UNDERSTAND THAT IF I AM NOT REDIRECTED TO REGISTRATION/PAYMENT
SITE I SHOULD CONTACT THE OFFICE TO CONFIRM MY ENROLLMENT *

Yes