Park Ridge Kids
Kids Connection
Registration
Wait List Form
B.L.A.S.T. Registration
Preschool
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
*
January
February
March
April
May
June
July
August
September
October
November
December
Year
*
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
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
*
January
February
March
April
May
June
July
August
September
October
November
December
Year
*
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
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
*
Month/Day/Year
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
*
By entering your name here, you are stating that you have read, understood, and will comply with the authorization statement.
Date
*
Month/Day/Year
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
Kids Connection
Registration
Wait List Form
B.L.A.S.T. Registration
Preschool