KCC Preschool Registration 2024-2025 • North Central Church

Thank you for your interest in enrolling your preschooler in Kid Central CNY's Preschool Program.

Our preschool program for 3 year olds is 3 days/week M/W/F from 9-11:30a - OR - 5 days/week M-F 9-11:30a.

Our preschool program for 4 year olds is 5 days/week M-F 9-11:30a.

Registration fee (non refundable): $100. 20% discount if registration is received by March 31, 2024 (Invoice will be sent via email. Payment can be made online; click the link within the email.)

Please follow the steps below and submit:

Step 1 - Complete all fields in the form below for each child being registered.

Step 2 - Submit form.

After registration form is submitted and processed, you will be contacted via email with the additonal items needed to fully complete the registration process.

We are looking forward to serving your family at Kid Central CNY Preschool!

NOTE: This form will "time-out" if left unattended. Be sure to have the following information ready before beginning - medical insurance & 2 emergency contacts information.

Program Applying For

Check One *

3 year olds (3 days/wk) Mon/Wed/Fri 9-11:30a

3 years old (5 days/wk) Mon - Fri 9-11:30a

4 year olds (5 days/wk) Mon - Fri 9-11:30a

General Information

Child's First Name *

Child's Last Name *

Home Address *

Home Address Line 2

Home City *

Home State *

Home Zip Code *

Primary Language *

Date of Birth *

Child's Current Age *

Gender *

Does your child have any disabilities, chronic medical conditions, or allergies which require special consideration or care by Kid Central CNY staff? *

Yes

If yes, please give details.

Does your child need a 1:1 aide? *

Yes

Is your child currently taking regular medications? *

Yes

If yes, please describe your child's regular medications.

Parent/Guardian Information

Primary Contact First Name *

Tip: *this will be the primary account contact for billing and communications

Primary Contact Last Name *

Cell Phone Number *

Email Address *

Employer Name *

Employer Phone *

Address (if different from child)

Secondary Contact First Name

Secondary Contact Last Name

Cell Phone Number *

Tip: Note: If a secondary contact is not listed, please re-enter the primary contact's cell phone number.

Email Address

Employer Name

Employer Phone

Address (if different)

Emergency Contact/Authorized Pick-Up Information

In the event of an emergency when I may not be reached, Kid Central CNY staff may contact the following individuals whom I authorize to take my child from the child care premises.

Note: (2) Emergency Contacts are required. Copy of driver's license required for each person.

Emergency Contact Name 1 *

Relationship to Child *

Emergency Contact # 1 Phone Number *

Address *

Emergency Contact Name 2 *

Relationship to Child *

Emergency Contact # 2 Phone Number *

Address *

Child's Physician/Insurance Information

Name of Practice *

Physician's Name *

Phone Number *

Address *

*Please provide a copy of your child's current physical prior to his/her first day of preschool.

Date of Last Physical Examination

Medical Insurance Information

Subscriber's Name *

Type of Insurance *

Policy/ID Number *

Permissions & Authorizations

The below digital signatures shall constitute an original for all purposes set forth. Please provide full name.

Emergency Medical Treatment Authorization

I hereby give Kid Central CNY staff members permission to administer basic first aid and/or CPR to my child, as named below, and/or take my child, as named below, to a hospital for medical treatment when I cannot be reached or when delay would be dangerous to my child's health.

Child's First/Last Name *

Parent/Guardian Digital Signature *

Today's Date *

Parental Visit Notice

I understand that I may visit the Kid Central CNY Preschool programming unannounced at any time during the hours that my child is in care.

Parent/Guardian Digital Signature *

Today's Date *

Permission to Administer Over-The-Counter Topical Products

I give permission to Kid Central CNY to apply the topical, over-the-counter products I have checked below to my child, according to the label and/or package instructions. I agree that a brand name or generic product will be used, unless I have supplied Kid Central CNY with a specific product brand. All parent-supplied over-the-counter products must be kept in their original packaging and labeled with child's first and last name. Please bring in products that have a printed expiration date on the packaging.

Topical Products to Administer (Please select all that apply.) *

Child's First/Last Name *

Parent/Guardian Digital Signature *

Today's Date *

Policy Regarding Release of Children

I understand that Kid Central CNY accepts responsibility for my child upon his/her arrival to the program. Kid Central CNY will not be responsible after my child leaves the program as authorized on the enrollment form. Chidren will be allowed to leave the program with persons other than the parent only if written permission has been given to Kid Central CNY staff. I understand that any changes to the arrival/departure arrangements must be made in writing to the Kid Central CNY staff.

Parent/Guardian Digital Signature *

Today's Date *

Authorization for Photographs and Video Recording

Photography/Videography Permission (Please select one option.) *

I GIVE permission for my child to be photographed and videoed in Kid Central CNY LLC. I further consent to the use of these images/videos for communication purposes, display within the facility, and for publication on information materials, websites and social media.

I DO NOT GIVE permission for my child to be photographed and videoed at Kid Central CNY programming and activities.

For Office Use: