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Staff initials



Today’s Date:_________ New Member__________ Renewal________ Member since: _________ How did you hear about our program? (circle what applies): friend Family: family school flyer staff Name of referring

Advertisement (state which): Greensheet___ Face Book Website ____ Flyer _______ Special event____ Other:__________________ NAME OF ENROLLING PARENT: PARENT EMAIL: Name of Child: Age: School: Entering Grade: BEST # TO REACH YOU:

List any behavioral or other concerns we should be aware of FAMILY NEEDS: (Check all that apply)

Do you receive Coordinated Child Care subsidy? Y N I expect that my child will attend weekly. Y N (I understand that I am responsible for 50% of weekly tuition for the week(s) my child is not in attendance to hold her spot.) We must have your arrangements in writing in the admin office to properly bill your account. You will not be charged for winter break as we are closed. Please Provide: Copy of any court order/custody paperwork if applicable: OFFICIAL USE ONLY: Registration Due: $______ Date of Payment: ______ Form of Payment: Check #_______ Money Order Credit Card PayPal --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Kingdom Scholars 1. DO respect staff and others. 2. DO walk in the center. 3. DO keep your hands/feet to yourself. 4. DO participate in all activities. 5. DO listen to staff. 6. DO remain seated at all times during each bus/van ride 7. DO respect Girls Inc property and property of others Kingdom Scholars believes that each child has the right to be safe while within a Scholars inc. environment. Therefore, Scholars inc. has a zero tolerance policy for bullying, to include NO put-downs, shaming, name calling, taunting, 8. DO speak quietly. 9. DO say please and thank you. 10. DO play safely. 11. DO sit in a chair – not on tables. 12. DO use good language. 13. DO HAVE FUN! Tuition Due: $______ Amount Paid: $______

teasing, threats, or physical aggression of any student. Please support your child in helping them to understand the importance of our Code of Conduct. When an issue arises, a staff member will speak with the child and communicate any concerns to you so that we may work together to resolve any concerns. Time out of a program or activity may be given. Serious problems may result in a telephone call asking you to pick up your child, or a temporary 1-3 day suspension from our program. Spanking or any other form of physical punishment is prohibited by all child care personnel”. Parent/Guardian Initials: _____ Student/Childs Initials_______ Transportation Policy Kingdom Scholars will never release your child/children to anyone but the people you have listed! Medical Release Kingdom Scholars has my permission to administer minor first aid and seek emergency medical care when deemed necessary. Parent/Guardian Initials: ______

Supervision/Security Policy I understand that my child will not be left alone nor be allowed to leave the center without adult supervision am totally responsible for my child’s well-being and safety before and after hours on the property of Kingdom Scholars Parent/Guardian Initials: ______

Public Relations Release I give permission (without compensation) for Kingdom Scholars to use my child’s name, photograph, video image, or television production for public relations/promotional purposes. Parent/Guardian Initials: ______

Trips and Excursions Permission Statement I understand that during the school year Kingdom Scholars may plan special field trips as part of the Thanksgiving and Spring breaks or at other times. I give permission for my child to attend scheduled field trips. I understand that my child will remain under the supervision of Kingdom Scholars staff at all times. Parent/Guardian Initials: ______

Release of Liability/Assumption of Risk I agree to hold harmless Kingdom Scholars administration, staff & outside program providers, & assign & release the same from any liability for any injury of illness that may be suffered by the participant named herein, arising out of, or in any way connected with our school year program. Parent Initials: ______ By signing below I acknowledge that I have read, understand, and agree to all policies, releases and statements contained in this document.

Parent/Guardian Signature: __________________________________________Date:___________

Thank you for providing the following information, which is collected solely for statistical reporting and is kept confidential. This information will be kept anonymous. Participant Age 1-4 5-8 9-11 12-14 15-17 _______ African American Asian American Caucasian Latina/Hispanic Native American Pacific Islander Other, please indicate Participant lives with both parents Mother only Father only Joint Custody Parent & Stepparent Grandparent(s) Other Unknown Foster Parents Children: Participant Race/Ethnicity (check only one line) Multi-Ethnic

Military Family-(Y=Yes, N=No) _____ Annual Household Income $ 0 – 5,000 $5,001 – 10,000 $10,001 – 15,000 $15,001 – 20,000 $20,001 – 25,000 $25,001 – 30,000 $30,001 – 35,000 $35,001 – 40,000 Over $40,000

(one parent at a time)

Total Number of People Living in the Household: Adults: Number of adults in the home out of work: Number of adults in the home looking for work: Parent/Guardian Highest Level of Education Completed Middle School Some high school High school degree Voc. /Technical Training_______ Two year college degree Bachelor’s degree Graduate degree Primary Language Spoken at Home: Other languages spoken other than English:

RELEASE FOR EMERGENCY CARE This form must be the original notarized form, Contain only one child’s name, and be updated annually. PLEASE FILL OUT COMPLETELY: NO BLANKS OR FORM CANNOT BE ACCEPTED Child’s Full Name: Allergies: Birthdate: Medicines Routinely Taken:

Name of Custodial Parent(s)/Legal Guardians: Address: Street Address (number, street) Home Phone ( Home Phone ( Address Street Address (number, street) Telephone: ( Address Street Address (number, street) Telephone: ( Hospital Preference: Medical Insurance Company: Policy #: ) ) Family Dentist or Health Dept used for dental care/emergencies: ) ) Cell Phone ( Cell Phone ( ) )


State Work Phone ( Work Phone ( ) )


Family Physician’s Name/Health Care Resource: City State Zip




Expiration Date:

Emergency Contact (if custodial parent/guardian cannot be reached): Address: Street Address (number, street) Home Phone ( ) Cell Phone ( ) City State Work Phone ( ) Zip

Sign in the presence of the Notary. I hereby give my consent to any emergency facility and physician to administer necessary treatment to my child, in the event of an emergency at which time (Child’s full name) I cannot be reached. I give consent to transport by ambulance if situation warrants it.

Signature of Custodial Parent/Legal Guardian (Affiant) STATE OF TEXAS The foregoing instrument was acknowledged before me on (Month) by (Name of Affiant) NOTARY produced (Type of identification) Signed: 20 (Day) (Year) , who is personally known to me or who has SEAL as identification. ,


(Signature of Notary)