KLUBHOUSE KIDS, INC.
2017-2018 APPLICATION
NON-REFUNDABLE REGISTRATION FEE - $25 PER FAMILY
$100 SECURITY PER FAMILY
CHILD’S NAME BIRTHDAY M/F Last First
STREET TOWN ZIP CODE
PARENT/GUARDIAN HOME PHONE CELL PHONE
EMPLOYER WORK PHONE
EMPLOYER ADDRESS EMAIL
PARENT/GUARDIAN HOME PHONE CELL PHONE
EMPLOYER WORK PHONE
EMPLOYER ADDRESS EMAIL
PERSONS, OTHER THAN PARENTS, WHO ARE ALLOWD TO PICK-UP YOUR CHILD:
NAME PHONE
NAME PHONE
PERSON WHO MAY NEVER PICK-UP YOUR CHILD:
NAME
HEALTH CONDITIONS:
DOCTORS NAME PHONE
SCHOOL TEACHER GRADE
PLEASE CIRCLE DAYS FOR WHICH CARE IS NEEDED: MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY
MY CHILD is in good health.
I understand that I will be given several days notice if a special activity is planned. Specific information on special activities will be provided as they are scheduled.
By signing below, I also give my permission for my child to participate in walking field trips.
If parents cannot be reached in an emergency, the Klubhouse Kids staff will call the local rescue squad to take your child to a medical facility for emergency care. Continued efforts will be made to reach you. Your signature below indicates approval for this procedure.
Signature of parent/guardian Date
I have received a copy of the Parent Handbook. P/G Date
I have received a copy of the DCF Information to Parents notice. P/G Date
I have received a copy of the Klubhouse Kids Policy on Communicable Diseases. P/G Date
I have been informed that the Klubhouse Kids site has a copy of the NJ State School Age Child Care Regulations Manual available for my inspection. P/G Date
I have been informed that the Klubhouse site has a copy of the Federal Unsafe toy list. P/G Date
I have received a copy of the center’s policy on the expulsion of children from enrollment.
P/G Date
North Plainfield Families: Warren Families:
Applications can be mailed to: Applications can be mailed to: Klubhouse Kids, Inc. Klubhouse Kids, Inc. 15 Fieldstone Road 90 Myrtle Avenue Califon, New Jersey 07830 North Plainfield, New Jersey 07060