<p> KLUBHOUSE KIDS, INC . 2010-2011 APPLICATION</p><p>NON-REFUNDABLE REGISTRATION FEE - $25 PER FAMILY______$100 SECURITY PER FAMILY______</p><p>CHILDS NAME______BIRTHDATE______M/F______LAST FIRST</p><p>STREET______TOWN______ZIP CODE______</p><p>PARENT/GUARDIAN______HOME PHONE______</p><p>EMPLOYER______WORK PHONE______</p><p>EMPLOYER ADDRESS______EMAIL______</p><p>CELL PHONE______</p><p>PARENT/GUARDIAN______HOME PHONE______</p><p>EMPLOYER______WORK PHONE______</p><p>EMPLOYER ADDRESS______EMAIL______</p><p>CELL PHONE______</p><p>PERSONS, OTHER THAN PARENTS, WHO ARE ALLOWED TO PICK UP YOUR CHILD:</p><p>NAME______PHONE______</p><p>NAME______PHONE______</p><p>PERSON WHO MAY NEVER PICK UP YOUR CHILD:</p><p>NAME______</p><p>HEALTH CONDITIONS:</p><p>DOCTORS NAME______PHONE______</p><p>SCHOOL______TEACHER______GRADE______</p><p>PLEASE CIRCLE DAYS FOR WHICH CARE IS NEEDED: MONDAY TUESDAY W EDNESDAY THURSDAY FRIDAY My child ______is in good health.</p><p>Signature of parent/legal guardian Date</p><p>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.</p><p>By signing below, I also give my permission for my child to participate in walking field trips. </p><p>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.</p><p>Signature of parent/legal guardian Date</p><p>******************************************************************************************************************************* ******************</p><p>I have received a copy of the Parent Handbook.</p><p>Signature of parent/legal guardian Date</p><p>******************************************************************************************************************************* ******************</p><p>I have received a copy of the DYFS Information to Parents notice. ______Signature of parent/legal guardian Date</p><p>******************************************************************************************************************************* ******************</p><p>I have received a copy of the Klubhouse Kids Policy on Communicable Diseases. ______Signature of parent/legal guardian Date</p><p>******************************************************************************************************************************* ****************** 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.</p><p>______Signature of parent/legal guardian Date</p><p>******************************************************************************************************************************* ******************</p><p>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</p>