B.L.A.S.T. Registration

B.L.A.S.T. Registration Form

Wednesday BLAST

Check here to show when your child will be picked up: *

My child will be picked up at PRCC by 4 p.m. I will register my child at prkids.org for after-school care at Kids Connection (PRCC) at $10/Wednesday and pick up my child by 6:00 p.m. (Must confirm RSVP via phone).

* Indicates required field

Today's Date *

Requested Start Date: *

Child's Name *

First

Last

Birthday *

Child's Age: *

Gender *

Male Female

School Child Attends *

Grade Level *

School Teacher *

Church Home (if applicable) *

Father/Guardian's Name *

First

Last

Mother/Guardian's Name *

First

Last

Father's Email *

Father's Cell Phone *

Father's Work Place *

Father's Work Number: *

Mother's Email *

Mother's Cell Phone *

Mother's Work Place *

Mother's Work Number *

Child Lives With: *

Emergency Contact First Name *

Emergency Contact Last Name *

Cell Phone Number *

Comment *

2nd Person authorized to pick up child (not parent or emergency contact) *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Child's Doctor *

Doctor's Phone Number *

Most Recent Medical Appointment Month *

Year *

Person authorized to pick up child (not parent or emergency contact) *

Phone Number *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Address *

Line 1

Line 2

City

State

Zip Code

Country

Preferred Hospital *

Child's Dentist *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Most Recent Dental Appointment Month *

Year *

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 first visit with my payment. *

Yes No

I have read, understand, and agree to the policies in the Parent Handbook. I entrust the care of my child to the staff at Kids Connection and will instruct him/her to respect and follow the clear limits set for safe behavior.
I also give permission for Kids Connection staff to transport my child to and from their school, other schools on their route, and to and from scheduled destinations and field trips; both during this school year and summer day camps following.
If I cannot be reached, or before I am reached, in an emergency, my child may be treated by medical personnel as required.
My child may be released to those adults listed on this registration form, or a staff person may transport my child home with verbal confirmation from either myself or the designated responsible person.

Signature *

Date *

I authorize Kid's Connection and/or Park Ridge Kids 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. I give consent to Kid's Connection and/or Park Ridge Kids designated staff, to seek medical care and treatment of my child in the event of injury or illness if I cannot be reached. I give permission to Kid's Connection and/or Park Ridge Kids to transport my child to and from scheduled destinations. If my child is attending Before/After School Care and/or Summer Day Camp, I acknowledge that I have downloaded and read the Park Ridge Kid's Connection Parent Handbook. I understand all policies contained and agree to the terms described within the handbook.

Signature *

Date *

Submit

Kids Connection Parent Handbook.pdf
File Size:	1053 kb
File Type:	pdf

Download File

Kids Connection Health Policy.pdf
File Size:	417 kb
File Type:	pdf

Download File