Enrollment Form

child's last name	1st name	DOB             M     F	School Child Attends		Any allergies or special needs?
		M     F			NO     YES:
		M     F			NO     YES:
		M     F			NO     YES:
		M     F			NO     YES:
Lives with (circle):	Mother	Father	Child's Doctor's Name		Doctor's Phone #
last name
first name
street address			Emergency Contact/Authorized Release Persons- Names & Addresses
City/State/Zip			Last name		2
home phone			1st Name
Cell phone #			street
WORKPLACE			City
street address			State
City/State/Zip			Zip
Work phone #.			Phone
*My child/ren may be released to custodial parents, persons listed above or				anyone designated on the daily check-in form.
I authorize the center to obtain emergency medical treatment in case of an emergency.  I understand that I am responsible for all charges incurred.
* I have received a copy of Kids' Stay 'N Play Policies.  I have read the back of this form and agree to abide by all policies.
A. Supervisor:____________________________		Your Signature:_________________________________________Date:_____________________
1.  Kids' Stay 'n Play provides a safe and caring environment for your child.  Free morning, afternoon and evening snacks are offered
to all children in attendance (infants, see policy).			Complete a meal ticket at check in.  All children are served.
			Meals are an extra charge if not included in your rate plan.
2. I understand that Kids' Stay 'N Play does not accept ill children.  Parents will be notified if their child becomes ill or injured.
I understand that Kids' Stay 'N Play will make all reasonable efforts to provide for the safety of my child.  I also understand that in
the normal course of a child's activity it is possible that he or she may become injured.  In the event my child becomes injured
while at the center through no fault of Kids' Stay 'N Play, it's agents, or employees, I agree to release and indemnify Kids' Stay 'N
Play, it's agents and employees from liability.
3.  I AGREE TO KEEP THE CENTER INFORMED OF CHANGES IN PERSONAL INFORMATION THROUGH THE YEAR.
4.  My child(ren) is up to date on immunizations required.  I will provide immunization records within 30 days.
5.  I have listed any allergies or other physical problems, mental health disorders, mental retardation or developmental disabilities
which would limit my child's participation in the center's programs and activities in the space provided on the front of this form.
6.  I have listed any special procedures to be followed in caring for my child, including any special services which the center agrees
to provide to a child with special needs.
7.  I understand that the center will only dispense medication in the original bottle with my child's prescription and name on the
bottle.  The Authorization for Medication form must be completed by you in order for the Center to administer prescribed medicine.
8.  I understand that when I, or persons authorized, pick up or drop off my child/ren, they will be escorted and that the center
will not permit the child to enter or exit without an escort.
9. I UNDERSTAND THAT INFANT RESERVATIONS ARE REQUIRED WITH A MINIMUM 2 HOUR PRE-PAID RESERVATION.
CANCELLATIONS LESS THAN 4 HOURS IN ADVANCE ARE NON-REFUNDABLE, AS WELL AS NO SHOWS.
10.   Should I choose to make a phone reservation with the use of a credit card, I authorize Kids' Stay 'N Play to charge my account.
I understand cancellations less than 48 hours in advance are non-refundable.
11.  Photographs of the above named child (ren) may be used for promotional use.
				Signature on front indicates you agree.