Bethany Kid's Club Registration

Bethany UMCKidsCare

K5 – 5th grades

General Registration Form

First enrollment ____ Returning family ____

Child's Full Name______Preferred Name______Date of Birth ______

Age: (as of 9/1/2017) _____ Gender M F Grade: (2017-2018 school yr.) _____ School attends ______

Home Address______Home phone______

City______State______Zip______

Mother's Name______Cell Phone______

Mother’s place of business ______Work phone ______

Moher’s occupation ______Mother’s Email address ______

Father's Name______Cell Phone______

Father’s place of business ______Work phone ______

Father’s occupation ______Father’s Email address ______

Alternative email for daytime hours______Text #______

Are parents separated? Y N Divorced? Y N Church affiliation ______

Special Needs statement: Bethany UMC KidsCare believes every child is a special gift from God and strives to meet the physical, social, spiritual, and emotional needs of the children it serves. Enrollment of children with special educational needs will be evaluated on a case by case basis to determine if KidsCare is able to meet their needs. The decision will be based upon review of any and all professional evaluations of the child’s assessment of his/her individual needs and the impact on the classroom.
If it is determined that the enrollment of the child will not require fundamental changes to the program or classroom and our staff has training and experience to properly serve the need of the child, provisional enrollment will be granted on a trial basis. If it is determined the program cannot best serve the needs of the child, the child will not be enrolled, their registration fee will be refunded and the parents will be directed to resources that can better serve the child.

Return the completed form to:

Bethany U.M.C. KidsCare

118 W.3rd South St., Summerville, SC 29483

Office (843) 873-1230 ex 36

Cell (843) 460-4837

Fax (843) 873-1937

Health and Emergency InformationChild’s name ______

Allergies ______Severity______

Type of Reaction______Emergency Treatment______

Medications taken regularly______

Family Doctor/Pediatrician______Phone______

Other information pertinent to your child’s care (this will be kept confidential)______

______

Emergency Contacts(other than parents) Pick-up permission?

Name______Phone______Cell______Yes No

Emergency Release

Our procedure in case of emergency, such as sudden illness is, (1) to render first aid (2) contact parents for instructions (such as transportation to home, doctor to be called, and/or hospital preference if necessary). In some cases, failure to establish a contact with either parent could delay treatment. Only after reasonable efforts have been made to contact you, will we call your doctor, and only in life threatening or extreme cases will your child be transported to the nearest hospital.

I hereby grant permission for the Director and/or Counselors of Bethany Kid's Camp, or emergency and/or hospital staffs, to take whatever steps necessary to obtain and provide emergency medical care if warranted.

______

Signature of Parent or Guardian Date Hospital Preference

Pick Up Policy

Only Mom or Dad or the people listed below as having parental permission, will be allowed to pick up your child. Any other arrangements, either temporary or permanent, must be given in writing. A picture ID will be required if we do not know the person picking up.

NameRelationshipPhone Cell

______

Payment Policy

I have read the attached payment policy. I will direct any questions to the KidsCare director. Initial: ______

Field Trips

I give my permission for my child to participate in field trips and activities and waive all claims against the leaders of these trips, any person(s) that has provided transportation for which I have given my approval, all officials of Bethany United Methodist Church, Summerville, SC and all representatives of the United Methodist Church. Initial: Yes ____ No ____

Pictures

I also give my permission for my child's picture to be taken while at KidsCare and for those pictures to be printed or used for KidsCare materials.. Initial: Yes ____ No ____

Movies

Please give your preference for the type of movies you child may watch. Initial: G rated only ____ G & PG rated ____

Parent Signature______Date______Rev. 02.14.2018