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Your Contact Info
Day Care Agreement
Emergency Contact/Parental Consent
General Information
Parent Name(s)
Child(ren) names
School Name
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KPOC-4601 Market St
KPEA-2409 W. Westmoreland St
KWPEA-5070 Parkside Ave
Grade
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K
1
2
3
4
Payment Type
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CCIS
Self Pay
Parent Email Address
Parent Cell Phone Number
Enrollment Type
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Enrolled
Waitlist
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Day Care Agreement
Name of Child
Fee Amount
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$60 Self Pay
CCIS Copay
CCIS Copay Amount, if applicable
Per Day/Week
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Day
Week
Day Payment to Be Made
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Option 1
Option 2
Services to Be Provided
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Before/After Care
Before Care
After Care
Childs Arrival Time
Childs Departure Time
Late Fee
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$1/min
Persons Designated by Parent to Whom Child May Be Released
Extra Services To Be Provided at an Additional Fee if Applicable
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NA
Received Completed Written Program Information at the Time of Enrollment (With Applicable Codes)
Agree To Update the Emergency Contract / Parental Consent Form Information Whenever Changes Occur or Every 6 Months at a Minimum (With Applicable Codes)
Parent/Guardian Signature
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Parent/Guardian Signature Date
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Emergency Contact/Parental Consent
Child's Information
Child's Name
Child's Date of Birth
Child's Home Address
Parent/Guardian Information
Parent/Guardian Name
Home Phone
Home Address
Business Name
Business Address
Business/Work Phone Number
Parent/Legal Guardian #2 Name
Parent #2 Home Telephone number
Parent #2 Home Address
Parent #2 Business Name
Parent #2 Business Telephone Number
Parent #2 Business Address
Emergency Contact Persons
First Person's Name
First Person's Telephone Number When Child Is in Care
Second Person's Name
Second Person's Telephone Number When Child Is in Care
Persons to Whom Child May Be Released
First Person's Name
First Person's Address
First Person's Telephone Number When Child Is in Care
Second Person's Name
Second Person's Address
Second Person's Telephone Number When Child Is in Care
Child's Physician/Medical Care Provider
Name
Telephone Number
Address
Special Disabilities (if any)
Allergies (including medical reaction)
Medical or Dietary Information Necessary in an Emergency Situation
Medication, Special Situation
Health Insurance Coverage for Child or Medical Assistance Benefits
Policy Number
Parent Signature Required for Each Item Below To Indicate Parental Consent
Obtaining Emergency Medical Care
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Walks and Trips
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Transportation by the Facility
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Administration of Minor First Aid Procedures
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Swimming
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Wading
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