537 Evangeline Trail

(337) 332-5444

537 Evangeline Trail

Breaux Bridge, LA 70517

Registration Checklist

• Contact Kinder Kollege Learning Center with any questions or concerns.

• Print, complete, and sign one registration application per child.

• Include a check or money order for the non-refundable registration fee of $100 per child. No registration fee is required for our drop-in program.

• Updated Immunization Records signed by physician.

• Individual Health Care Plan form signed by physician. (if applicable for your child)

If no spaces are available, your registration application and fees will be held on a waiting list at no additional cost. Siblings of Kinder Kollege students will be given priority in enrollment. Registration is on a first-come, first serve basis by postmark date.

Registration Form

Child’s Legal First & Last Name: ______Child’s Birth Date: ______

Desired Start Date: ______

Please note: To guarantee your child’s enrollment, KKLC approved start date may not be changed beyond the date written above.

Parent/Guardian #1 – Please check items below Parent/Guardian #2– Please check items below

□Primary Billing Contact □Primary Parent Contact□Primary Billing Contact □Primary Parent Contact

□Mr. □Ms. □Mrs.□Mr. □Ms. □Mrs.

______

First NameLast NameFirst NameLast Name

______

AddressAddress

______

CityState, ZipCityState, Zip

Please Note: A HOME phone number is required.

H= Home W= Work C= Cell

______

Phone #1 (List by Calling Preference) Circle One: H W CPhone #1 (List by Calling Preference) Circle One: H W C

______

Phone #2 Circle One: H W CPhone #2 Circle One: H W C______

Phone #3 Circle One: H W CPhone #3 Circle One: H W C

______

Employer Name Position TitleEmployer Name Position Title

______

Employer AddressEmployer Address

______

City State, ZipCity State, Zip

Current Child Information: (as of start date)

Gender (circle) / Height / Weight / Eye Color / Hair Color / Preferred Name / Known Allergies?
Male / Female

Authorization for E-mail and Text Messaging Use

E-mail and text messaging are important communication tools that Kinder Kollege Learning Center utilizes for reminders, curriculum information, closing emergencies, illness notices, photos of your child at school, and tuition statements. Please provide an e-mail address and cell phone number that is your preferred contact method.

Parent 1 Name: ______Cell Phone Number: ( ____)______

e-mail address

Parent 2 Name: ______Cell Phone Number: ( ____)______

e-mail address

Parent Signature: ______Date : ______

Kinder Kollege Learning Center admits students of any race, religion, and ethnic backgrounds.

Registration Financial Form

Child’s First Name: ______Child’s Last Name: ______

Schedule: / Monday / Tuesday / Wednesday / Thursday / Friday
Drop Off Time
Pick Up Time

Payment Plan- Please check oneComplete if you were referred by another parent

□ Bi-MonthlyReferred by: ______

□ Monthly

NOTICE

A Two-Week, non-refundable deposit is required at the time of registration. This is a non-interest bearing deposit.

This deposit will be applied to your last two weeks of childcare. KKLC requires a two week written notice before termination is in effect.

Tuition is due on the first day of attendance and the proceeding first day of the month or the first day of two week period (depending on payment option selected).

Tuition is due and payable whether your child is out due to sickness, vacation, holiday closing (with the exception of July Summer Holiday Week), weather emergency, or circumstances beyond our control, such as loss of power.

To guarantee your child’s enrollment, the start date may not be changed beyond the KKLC contract date written above.

Kinder Kollege Learning Center reserves the right to change tuition rates at any time.

Tuition is based on child to teacher ratios.

Parent’s Signature: ______Date: ______

Financial Form

For KKLC Use Only

Child’s Legal Name:______Registration Date: ______

Classroom Assignment:______

Program :

InfantToddler 1-2Toddler 3PreschoolSchool-Age

Amount $ / Payment Method
Registration Fee
Deposit (Bi-Monthly Rate) / Due on First Day of Attendance

Billing / Payment Notes:

______

______

______

______

______

______

Director Signature: ______Date: ______

Permission Form

Transportation

I am responsible for my child’s transportation to and from Kinder Kollege Learning Center. If I contract with a 3rd party, I will provide written documentation to release my child.

Parent’s Signature: ______Date: ______

Field Trip Permission

I give permission for my child to take nature walks and buggy rides while under the supervision of the staff of Kinder Kollege Learning Center. I understand that these field trips will be restricted to the Kinder Kollege parking lot and grounds.

Parent’s Signature: ______Date: ______

Topical Cream Permission

I give permission to the staff of Kinder Kollege Learning Center to apply topical cream for my child. Topical creams are defined as diaper rash ointments, calamine lotion, bug spray, and sunscreen. I understand that I am to provide the creams as they are needed for my child.

Parent’s Signature: ______Date: ______

Bike and Helmet Permission

I give permission for my child to ride age appropriate riding toys provided by Kinder Kollege Learning Center. I understand that Kinder Kollegedoes not provide helmets. If I want my child to wear a helmet I will provide a helmet, labeled with my child’s name.

Parent’s Signature: ______Date: ______

Parent Visitation

I understand that I may view my child at any time from the Kinder Kollege Learning Center lobby and may visit the classroom upon invitation for various class activities. I also understand that other relatives (other than mother or father) visiting would need permission and be accompanied by a parent.

Parent’s Signature: ______Date: ______

Photo Posting

I understand that Kinder Kollege Learning Center will take photographs of my child for allergy alert posting in the classroom. This posting is used in the interest of identifying my child with the KKLC staff to prevent possible allergic reactions.

Parent’s Signature: ______Date: ______

KKLC Picture TakingCheck One

□ I do□I do not

give permission for photographs to be taken of my child. I understand that these photos will be used for documentation, display, school projects, e-mailing parents, or classroom activities. I understand that these photos may include my child and other children in the classroom. These photos WILL NOTbe used for marketing activities without my written consent.

Parent’s Signature: ______Date: ______

Parent Photo Taking

I understand that other KKLC parents may want to take pictures of their child at special events in the center. Examples of special events may include Parent Invitations, Field Trips, School-Wide Activities, etc. Kinder Kollege Learning Center will do its best in asking parents to respect the privacy of our families but KKLC cannot guarantee that NO photographs will be taken of my child.

Parent’s Signature: ______Date: ______

Authorization for Emergency Care

I understand that every effort will be made to contact me in the event of an emergency requiring medical attention for my child. However, if I cannot be reached I authorize Kinder Kollege Learning Center to transport my child to the nearest hospital by ambulance and secure for my child the necessary medical treatment. I understand that the staff of KKLC are trained in the basics of first aid and CPR and I authorize the staff to give my child first aid and CPR when appropriate.

Parent’s Signature: ______Date: ______

Medical Contact Information

Name of Physician: / Phone Number:
Child’s Health Insurance Provider: / Child’s Health Insurance Phone Number:
Child’s Health Insurance ID Number:
Known Allergies: / Type of Reaction/Special Instructions:

Please Note: If your child has a diagnosed allergy or other diagnosed medical condition that we should be aware of, please complete the Individual Health Care Form for your child.

Emergency Contact & Release Form

Child’s Name: ______Date of Birth: ______

The Emergency Contact persons that you choose can make decisions about your child’s emergency care when parents cannot be reached. Please list contacts other than parents/legal guardians in the order to be contacted.

Two emergency contacts are required.to be listed below for us to release your child into their care. Be sure that the contact persons listed will be able to pick up your child within one hour of notification.You are financially responsible for any late fees incurred by the persons listed below.Your child will not be released to anyone other than those persons listed below without written instructions from the parent / legal guardian. Picture identification will be required in order to pick up a child.

Emergency Contact & Release

Emergency Contact #1
Name: / Phone Number:
Address: / Cell Number:
City, State, Zip: / Work Number:
Place of Employment: / Relationship to Child:
Do you give permission for your child to be released to this person? Yes No
Emergency Contact #2
Name: / Phone Number:
Address: / Cell Number:
City, State, Zip: / Work Number:
Place of Employment: / Relationship to Child:
Do you give permission for your child to be released to this person? Yes No
Emergency Contact #3
Name: / Phone Number:
Address: / Cell Number:
City, State,Zip: / Work Number:
Place of Employment: / Relationship to Child:
Do you give permission for your child to be released to this person? Yes No
Emergency Contact #4
Name: / Phone Number:
Address: / Cell Number:
City, State,Zip: / Work Number:
Place of Employment: / Relationship to Child:
Do you give permission for your child to be released to this person? Yes No

______

Parent/Legal Guardian SignatureDate

Please list any legal custody or restraining orderarrangements that Kinder Kollege should be aware of.

______

______

Child Development Form

Child’s Name: ______Date: ______

Infant and Toddler information is marked with an asterisk *

Development

Age of Child in Months: ______began sitting; ______crawled; ______walked; ______began talking

*Does your child: pull themselves up? Yes NoCrawl? Yes NoWalk with support? Yes No

Any speech difficulties? ______

Any special words to describe needs? ______

*Any history of Colic? ______*Does your child have a fussy time? ______

*How do you handle the fussy time? ______

*Does your child use a pacifier? Yes Nosuck thumb? Yes No

*If Infant is on special formula, describe preparation in detail. ______

*Is your child fed in lap? Yes NoHigh Chair? Yes No

Does your child eat with (check all that apply) hands? _____spoon?_____fork? _____

Favorite foods?______

Foods refused? ______

Restroom Habits

*Do you use disposable diapers? Yes No

*Is there a frequent occurrence of diaper rash? Yes No

*What diaper cream treatment do you use?______

Are bowel movements regular? Yes NoHow often? ______

Is there a history of diarrhea? Yes NoConstipation? Yes No

Has toilet training been attempted? Yes NoIs toilet training complete? Yes No

What is used at home? Potty chair?_____Special seat?_____Regular seat? _____

How does your child communicate bathroom needs? (any special words) ______

Does your child have accidents? Yes No

Any particular bathroom procedure? ______

Sleeping Habits

*Does your child sleep in a crib or bed? ______

Does your child nap during the day? Yes No When and how long? ______

What time does your child wake in the morning? ______

What time does your child sleep at night? ______

Describe any special characteristics or needs. (stuffed animal, blanket, mood when waking, etc. )______

The American Academy of Pediatrics recommends placing a baby on their back to sleep to reduce the risk of Sudden Infant Death Syndrome (SIDS). If your child does not regularly sleep on their back, please contact your pediatrician immediately to discuss the best sleeping position for your baby.

Kinder Kollege must have written permission to place an infant on their stomach or to swaddle an infant while in our care. Please speak with a director about providing this documentation.

Child Development Form

Health

Any known complications at birth? ______

Serious illness or hospitalizations? ______

Physical conditions / disabilities?______

Allergies? (i.e. asthma, insect bites, medications, food, etc.) ______

Any regular or daily medications? ______

If you answered positively on allergies or medications, please complete an Individual Health Care Plan form.

Social Relationships

How would you describe your child?______

Relationships with other children when at play? ______

Ability to play alone? ______

Reaction to strangers? ______

Any known fears? ______

How do you comfort your child’s fears? ______

Is your child currently receiving services from local, state, or privately contracted therapists? Yes No

If Yes, please provide a copy of your child’s IEP or documented therapy plan to Kinder Kollege Learning Center.

Will your child have therapy sessions on-site while attending KKLC? Yes No

What is the method of discipline/behavior management used at home? ______

What would you like your child to gain from their experience at Kinder Kollege? ______

Daily Schedule

Please describe your child’s daily schedule. (include eating, napping, restroom habits, fussy time, etc. )

______

Is there anything else that our educators should know about your child?

______

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Parent/Legal Guardian SignatureDate

______

Director SignatureDate

______

Teacher SignatureDate