Enrollment Form - Kid's Stay 'n Play

Enrollment Form

Please print this form, fill out all appropriate entries and sign it before visiting our nearest center. Thank You.

Children's Information

            Specify Needs/Allergies?
Lastname Firstname DOB Male Female School Child Attends?
Yes
 Explain
No
     
 
 
     
 
 
     
 
 
     
 
 
     
 
 

 

Parent's Information

Children live with?
Father
Mother
Lastname    
Firstname    
Address    
City    
State    
Zip    
Phone #    
Cell Phone #    
Workplace    
Work Address    
Work City    
Work State    
Work Zip    
Work Phone #    

 

Doctor's Information

Name: Phone #:

 

Emergency Contacts / Authorized Release Persons- Names & Addresses

Name    
Address    
City    
State    
Zip    
Phone #    

*My child/ren may be released to custodial parents, persons listed above or I authorize the center to obtain emergency medical treatment in case of an emergency. I understand that I am responsible for all charges incurred.
* I have received a copy of Kids' Stay 'N Play Policies. I have read the entirety of this form and agree to abide by all policies.

  1. I have checked the times my child will usually be eating at the Center:
    Breakfast A.M Snack Lunch P.M Snack Dinner Evenig Snack
  2. I understand that Kids' Stay 'N Play does not accept ill children. Parents will be notified if their child becomes ill or injured. I understand that Kids' Stay 'N Play will make all reasonable efforts to provide for the safety of my child. I also understand that in the normal course of a child's activity it is possible that he or she may become injured. In the event my child becomes injured while at the center through no fault of Kids' Stay 'N Play, it's agents, or employees, I agree to release and indemnify Kids' Stay 'N Play, it's agents and employees from liability.
  3. I AGREE TO KEEP THE CENTER INFORMED OF CHANGES IN PERSONAL INFORMATION THROUGH THE YEAR.
  4. My child(ren) is up to date on immunizations required. I will provide immunization records within 30 days.
  5. I have listed any allergies or other physical problems, mental health disorders, mental retardation or developmental disabilities which would limit my child's participation in the center's programs and activities in the space provided on the front of this form.
  6. I have listed any special procedures to be followed in caring for my child, including any special services which the center agrees to provide to a child with special needs.
  7. I understand that the center will only dispense medication in the original bottle with my child's prescription and name on the bottle. The Authorization for Medication form must be completed by you in order for the Center to administer prescribed medicine.
  8. I understand that when I, or persons authorized, to pick up or drop off my child/ren, that they will not be permitted to enter or exit without an escort. A photo I.D. is required at pickup in order for a child to be released. Failure may result in termination of services.
  9. I UNDERSTAND THAT INFANT RESERVATIONS ARE REQUIRED WITH A MINIMUM 2 HOUR PRE-PAID RESERVATION. CANCELLATIONS LESS THAN 4 HOURS IN ADVANCE ARE NON-REFUNDABLE, AS WELL AS NO SHOWS.
  10. Should I choose to make a phone reservation with the use of a credit card, I authorize Kids' Stay 'N Play to charge my account.
  11. I understand cancellations less than 48 hours in advance are non-refundable.
  12. Photographs of the above named child (ren) may be used for promotional use.
Your Signature:______________________ Supervisor Signature: ______________________ Date: ___________