Before & After School Registration -

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Kid's Connection Before & After School Registration

Child's Name *

First

Last

Birthday *

Parent/Guardian's Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

-

-

Email *

Names of people who are authorized to pick up your child *

Day's You Plan To Enroll *

Monday Tuesday Wednesday Thursday Friday

Before/After Option *

Both Before School After School

Child's Physician *

Phone Number *

-

-

Allergies *

Yes No

If Yes, please describe in detail *

Dietary Restrictions *

Medications Regularly Taken *

I have downloaded and completed the Immunization Record & will bring it to the center with my payment. *

Yes No

I authorize Kid's Connection to release my child to the persons designated above if there is an emergency involving my child and I cannot be reached by center staff, or I fail to pick up my child by the scheduled closing time and fail to contact the center and cannot be reached by staff. *

By entering your name here, you are stating that you have read, understood, and will comply with the authorization statement.

*Payment may be made in the form of cash or check at the center.

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