Kid Central CNY School Break Day Camp • North Central Church

Program Days Applying For

Winter Break February 15-18

Monday, February 15

Tuesday, February 16

Wednesday, February 17

Thursday, February 18

Drop Off Time

Pick Up Time

Spring Break March 29-April 1

Monday, March 29

Tuesday, March 30

Wednesday, March 31

Thursday, April 1

Drop Off Time

Pick Up Time

Child Information

Child's First Name *

Child's Last Name *

Primary Language *

Home Address *

Home Address Line 2

Home City *

Child's Date of Birth *

Child's Current Age *

Child's Gender *

Home State *

Home Zip Code *

Home Country

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 details below:

Does your child need a 1:1 aide?

Is your child currently take any regular medications?

Please describe your child's regular medications OR reply None if applicable:

Parent/Guardian Information

Parent/Guardian 1 First Name *

Parent/Guardian 1 Last Name *

Address (if different)

Email Address *

Mobile Number *

Parent/Guardian 2 First Name

Parent/Guardian 2 Last Name

Address (if different)

Email Address

Mobile Number

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.

Emergency Contact Name 1 *

Relationship to Child *

Emergency Contact Number 1 *

Emergency Contact Name 2 *

Relationship to Child *

Emergency Contact Number 2 *

Permissions & Authorizations

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

School Break Day Camp Activities Authorization

The child listed has my permission to participate in all Kid Central CNY School Break Day Camp activities.

I understand that Kid Central CNY and their sanctioned members are not liable in case of accident. I understand that every precaution will be taken to provide a safe and secure environment for my child. I assume all risks associated with the activities inherent to those environments.

Child's First/Last Name *

Parent/Guardian Digital Signature *

Today's Date *

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 *

Policy Regarding Release of Child

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. Children 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.

Child's First/Last Name *

Parent/Guardian Digital Signature *

Today's Date *

Authorization for Photographs and Video Recording

Please select one option. *

I GIVE permission for my child to be photographed and videoed in Kid Central CNY. 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.

Child's First/Last Name *

Parent/Guardian Digital Signature *

Today's Date *

Comments: