Kid Central CNY Remote Learning Center Registration (2020-2021) • North Central Church

Thank you for your interest in Enrolling in Kid Central CNY's Remote Learning Center. We are honored to work together with you and your child(ren).

Program Details:

$40/day/child
Advance Pay Discounts
Multiple Child Discounts
Full-Day Program (Monday-Friday) Openings
7:30a-4:30p
Grades 1-6

Includes:

WiFi
Chromebook Tech Support
Custom Coaching for Remote Learners
Recreation Breaks
Lunch & Snack Breaks (*Lunch, snacks and water bottle must be brought from home)
New, Clean, Safe & Secure Building
Child Worker Supervision

NOTE: This form will "time-out" if left alone, so have the following information ready before beginning - medical insurance & 2 emergency contacts information.

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.

Once registration form is submitted, you will be contacted to set up an appoinment to complete the final registration process. Please check your email for a confirmation email outlining what to bring with you to your appointment.

Looking forward to serving your family at Kid Central CNY!

Program Days Applying For

Start Date *

Drop Off Time *

Pick Up Time *

General Information

Child's First Name *

Child's Last Name *

Primary Language *

Child's Date of Birth *

Child's Current Age *

Child's Gender *

Home Address *

Home Address Line 2

Home City *

Home State *

Home Zip Code *

Home Country

School District Attending *

Child's School Grade

Name of Child's School *

Parent/Guardian Information

Parent/Guardian 1 First Name *

Parent/Guardian 1 Last Name *

Address (if different)

Email Address *

Phone Number *

Mobile Number *

Employer *

Employer Phone *

Parent/Guardian 2 First Name

Parent/Guardian 2 Last Name

Address (if different)

Email Address

Phone Number

Mobile Number

Employer

Employer Phone

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.

Contact 1 First/Last Name *

Relationship to Child *

Emergency Contact Phone Number *

Address *

Contact 2 First/Last Name *

Relationship to Child *

Emergency Contact 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 *

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

Tip: Please answer None if applicable.

Is your child currently taking any regular medications? *

Please describe your child's regular medications, OR reply None if applicable. *

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 write full name.

Emergency Medical Treatment Authorization

I hereby give Kid Central CNY LLC 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 Childcare 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 LCC to apply the topical, over-the-counter products I have checked off below to my below named child, according to the labe and/or package instructions. I agree that a brand name or generic product will be used, unless I have supplied Kid Central CNY LLC 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 *

Tip: 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 LLC accepts responsibility for my child upon his/her arrival to the program. Kid Central CNY LLC 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 *

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.

Tip: Please select one option.

For Office Use: