Klubhouse Kids, Inc

KLUBHOUSE KIDS, INC . 2010-2011 APPLICATION

NON-REFUNDABLE REGISTRATION FEE - $25 PER FAMILY______$100 SECURITY PER FAMILY______

CHILDS NAME______BIRTHDATE______M/F______LAST FIRST

STREET______TOWN______ZIP CODE______

PARENT/GUARDIAN______HOME PHONE______

EMPLOYER______WORK PHONE______

EMPLOYER ADDRESS______EMAIL______

CELL PHONE______

PARENT/GUARDIAN______HOME PHONE______

EMPLOYER______WORK PHONE______

EMPLOYER ADDRESS______EMAIL______

CELL PHONE______

PERSONS, OTHER THAN PARENTS, WHO ARE ALLOWED TO PICK UP YOUR CHILD:

NAME______PHONE______

PERSON WHO MAY NEVER PICK UP YOUR CHILD:

NAME______

HEALTH CONDITIONS:

DOCTORS NAME______PHONE______

SCHOOL______TEACHER______GRADE______

PLEASE CIRCLE DAYS FOR WHICH CARE IS NEEDED: MONDAY TUESDAY W EDNESDAY THURSDAY FRIDAY My child ______is in good health.

Signature of parent/legal guardian Date

I understand that I will be given several days notice if a special activity is planned. Specific information on special activities will be provided as they are scheduled.

By signing below, I also give my permission for my child to participate in walking field trips.

If parents cannot be reached in an emergency, the Klubhouse Kids staff will call the local rescue squad to take your child to a medical facility for emergency care. Continued efforts will be made to reach you. Your signature below indicates approval for this procedure.

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I have received a copy of the Parent Handbook.

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I have received a copy of the DYFS Information to Parents notice. ______Signature of parent/legal guardian Date

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I have received a copy of the Klubhouse Kids Policy on Communicable Diseases. ______Signature of parent/legal guardian Date

******************************************************************************************************************************* ****************** I have been informed that the Klubhouse site has a copy of the NJ State School Age Child Care Regulations Manual available for my inspection.

______Signature of parent/legal guardian Date

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North Plainfield Children: Warren Children: Application may be mailed to: Application may be mailed to 15 Fieldstone Road 90 Myrtle Avenue Califon, NJ 07830 North Plainfield, NJ 07060