KIDCO Child Care Center
2175 Berlin Turnpike Newington, CT. 06111 (860)667-7191
REGISTRATION FORM
DATE______DOOR CODE ______*
CHILD’S LAST NAME______FIRST NAME______
BIRTHDATE______AGE______GRADE ______BOY ______GIRL ______
HOME ADDRESS ______HOME PHONE ______
CITY ______STATE______ZIP CODE______
PRIMARY FAMILY E-MAIL______
MOTHER’S FULL NAME______HOME PHONE ______
HOME ADDRESS ______
OCCUPATION ______CELL PHONE______
PLACE OF EMPLOYMENT ______WORK PHONE______
WORK ADDRESS ______HOURS ______
FATHER’S FULL NAME ______HOME PHONE ______
HOME ADDRESS ______
OCCUPATION ______CELL PHONE______
PLACE OF EMPLOYMENT ______WORK PHONE ______
WORK ADDRESS ______HOURS ______
PARENT OR GUARDIAN WITH LEGAL CUSTODY ______
LIVES WITH MOTHER ______LIVES WITH FATHER ______
SIBLINGS? ______
HAS YOUR CHILD BEEN IN GROUP SITUATIONS BEFORE? ______
DOES YOUR CHILD BEHAVE IN GROUP SITUATIONS? ______
PRIMARY HOME LANGUAGE: ______
PLEASE LIST ANY OTHER INFORMATION YOU THINK IS IMPORTANT FOR STAFF TO KNOW ABOUT YOUR CHILD:
______
______
PLEASE LIST ANY HEALTH PROBLEMS, ALLERGIES ( FOOD OR MEDICATION ), OR OTHER
INFORMATION REGARDING YOUR CHILD THAT OUR STAFF SHOULD BE AWARE OF:______
______
CHILD’S DOCTOR ______PHONE ______
CHILD’S DENTIST ______PHONE ______
KIDCO Child Care Center 2175 Berlin Turnpike Newington, CT. 06111 page 2
ILLNESSES:
CHICKEN POX: ______DIPHTHERIA: ______WHOOPING COUGH: ______
MEASLES: ______POLIO: ______RHEUMATIC FEVER: ______
GERMAN MEASLES: ______EPILEPSY: ______CEREBRAL PALSY: ______
MUMPS: ______EAR INFECTIONS: ______
FAMILY HEALTH HISTORY:______
______
EMERGENCY CONTACTS & ADULTS AUTHORIZED TO PICK UP CHILD:
1. NAME ______HOME PHONE ______
RELATIONSHIP TO CHILD ______WORK PHONE ______
CELL PHONE______
Emergency Contact: Yes No Authorized to Pick Up Child: Yes No
2. NAME ______HOME PHONE ______
RELATIONSHIP TO CHILD ______WORK PHONE ______
CELL PHONE______
Emergency Contact: Yes No Authorized to Pick Up Child: Yes No
3. NAME ______HOME PHONE ______
RELATIONSHIP TO CHILD ______WORK PHONE ______
CELL PHONE______
Emergency Contact: Yes No Authorized to Pick Up Child: Yes No
PARENT(S) SIGNATURE ______
IF A CHILD IS NOT PICKED UP WITHIN ONE HOUR OF CLOSING TIME, WE WILL CONTACT LOCAL POLICE OFFICIALS.
EMERGENCY RELEASE
IN THE EVENT OF A MEDICAL EMERGENCY, I GIVE PERMISSION THAT MY CHILD
______BE GIVEN EMERGENCY TREATMENT BY A STAFF MEMBER CERTIFIED IN FIRST AID TRAINING. I ALSO GIVE PERMISSION FOR MY CHILD TO BE TRANSPORTED IN CASE OF A MEDICAL EMERGENCY TO THE NEAREST HOSPITAL.
PARENT’S SIGNATURE ______
IN THE EVENT OF AN ACCIDENT OR MEDICAL EMERGENCY AND A PARENT/GUARDIAN CANNOT BE CONTACTED, I GIVE PERMISSION FOR MEDICAL TREATMENT TO BE ADMINISTERED TO MY CHILD AS ADVISED BY AN ATTENDING PHYSICIAN OR OTHER EMERCENCY PERSONELL.
PARENT’S SIGNATURE ______
FIELD TRIP PERMISSION
I GIVE MY CHILD PERMISSION TO PARTICIPATE IN FIELD TRIPS OFFERED BY KIDCO IN WHICH THE CHILD MAY BE TRANSPORTED TO ANOTHER LOCATION BY THE KIDCO VAN OR PUBLIC TRANSPORTATION.
PARENTS SIGNATURE ______
PERMISSION TO PHOTOGRAPH ( OPTIONAL )
I GIVE PERMISSION TO KIDCO TO USE PHOTOGRAPHS OF MY CHILD ______
PARTICIPATING IN KIDCO ACTIVITIES FOR LOCAL NEWSPAPERS, OUR NEWSLETTER, PRESCHOOL FACEBOOK PAGE AND/OR THE KIDCO WEB SITE.
PARENT’S SIGNATURE ______
TRANSPORTATION PERMISSION (BEFORE/AFTER SCHOOL ONLY )
I GIVE PERMISSION FOR MY CHILD ______TO BE TRANSPORTED TO AND FROM ______SCHOOL AND THE KIDCO CENTER BY MEANS OF THE KIDCO VANS. THE VANS WILL ALSO BE USED TO TRANSPORT MY CHILD DURING FIELD TRIPS. PARENTS SIGNATURE ______
______
PROGRAM CHOICE: UNDER 5 YEARS
INFANT ______WADDLER ______TODDLER______
MON ______TUES ______WED ______THUR ______FRI ______HOURS ______to ______
3 & 4 YEAR OLDS - FULL TIME ______NURSERY SCHOOL (9-11:30) ______
MON ______TUES ______WED ______THUR ______FRI ______HOURS ______to ______
SCHOOL AGE PROGRAM
KINDERGARTEN:
BEFORE & AFTER ______BEFORE ONLY ______AFTER ONLY ______
SCHOOL ______AM KIND. _____ PM KIND. _____ FULL DAY _____
AGES 6 THRU 12:
BEFORE AND AFTER SCHOOL ______BEFORE SCHOOL ONLY ______
SCHOOL ______
TO BE FILLED OUT AT OFFICE:______
DATE OF REGISTRATION: ______START DATE: ______
ROOM ______TUITION RATE PER WEEK ______
REGISTRATION FEE __$50______DATE PAID ______
SECURITY DEPOSIT ______DATE PAID ______
* This form must be accompanied by the $50 registration fee to hold a spot. A two week deposit is also due prior to a start date.