Child’s Name: ______
(First / Middle / Last Name)
Child’s Home Address: ______
City: ______State: ______Zip: ______
Home Phone Number:______Date of Birth:______
Month/Date/Year
Any Allergies or Special Needs: ______
______
Sex: M ______F ______Grade Going In To: ______
PLEASE NOTE: All persons picking up a child must report to a PEM Kidz Club staff person and will be asked to show a picture ID unless known by PEM Clubhouse staff.
Parent/Guardian #1: ______
(First Name) (Middle) (Last Name)
Home Address: ______City/State/Zip: ______
Home Phone #: ______E-mail Address: ______
Employer: ______
Work Address: ______City/State: ______
Work Phone #: ______Ext: ______Cell #: ______
*Billing will be emailed the second week of the following month to Parent/Guardian #1. If you want a paper copy you will need to specify that to staff.
Parent/Guardian #2: ______
(First Name) (Middle) (Last Name)
Home Address: ______City/State/Zip: ______
Home Phone #: ______E-mail Address: ______
Employer: ______
Work Address: ______City/State: ______
Work Phone #: ______Ext: ______Cell #: ______
Primary Residents:
__ Both Parent/Guardian __Both Parent/Guardian (50/50) __ Parent/Guardian #1 __ Parent/Guardian #2
PRIMARY ALTERNATE CONTACT(if parent/guardian cannot be reached)
Name: ______Relationship to Child: ______
Home Address: ______City/State/Zip: ______
Home Phone #: ______E-mail Address: ______
Employer: ______
Work Address: ______City/State: ______
Work Phone #: ______Ext: ______Cell #: ______
SECONDARY ALTERNATE CONTACT(if parent/guardian or primary alternate cannot be reached)
Name: ______Relationship to Child: ______
Home Address: ______City/State/Zip: ______
Home Phone #: ______E-mail Address: ______
Employer: ______
Work Address: ______City/State: ______
Work Phone #: ______Ext: ______Cell #: ______
PEOPLE PERMITTED TO PICK UP MY CHILD (other than guardians or emergency contacts):
PEM Clubhouse will only release your child to persons you authorize. List below persons authorized to pickup your child including older siblings, grandparents, other relatives, family friends, etc):
Name: ______Relationship to child: ______
Name: ______Relationship to child: ______
Name: ______Relationship to child: ______
Name: ______Relationship to child: ______
If you have a person not authorized to pick up your child please submit it in writing to KidzClub staff with any court documents available.
PEM KIDZ CLUBHOUSE
CHILD'S HEALTH HISTORY
Child’s Name: ______Date of Birth: ______
Child’s Physician: ______Medical Clinic: ______
Address: ______Phone #:______
Hospital: ______Phone #: ______
Child’s Dentist: ______Dental Clinic: ______
Address: ______Phone #: ______
Insurance Coverage/Policy Number ______
Any allergies: ______
Medications: ______
Any other medical conditions, history, or special needs (physical, mental, or behavioral) that we
should be aware of______
______
Activity Restrictions: ______
I hereby authorize the Staff and/or Program Coordinator, representing PEM Clubhouse to give consent for any and all necessary emergency medical and first aid care for my child while my child is in custody. I understand that I will be responsible for all medical expenses (i.e. hospital, clinic charges).
______
Signature of Parent or Legal Guardian Date
______
Signature of Parent or Legal Guardian Date
REGISTRATION/PARTICIPATION LEVEL
You must complete a registration form and pay the per child registration fee in order to participate in PEM Kidz Club SACC summer program at any of the participation levels (full time, half day, part time, or drop-in)
____ $25.00 per child on or before May 1st early registration deadline
____ $35.00 per child after May 1st early registration deadline (as space is available)
NOTE: Registration fee must be paid at time registration form is submitted in order to reserve your child’s spot in the summer program.
PLEASE NOTE:Actual scheduling and invoicing will be based on participation/ attendance calendars that are submitted throughout the summer, the following information will be used for planning purposes. A limited number of children will be allowed to register at each participation level.
REGISTER MY CHILD AT THE FOLLOWING PARTICIPATION LEVEL (this is an estimation for registration purposes):
___ FULL DAYS (more than 6 hours)I anticipate my child will attend PEM Kidz Club summer program on a “full day” basis (more than 6 hours) on average ______days per week.
___ HALF DAYS(less than 6 hours)I anticipate my child will attend PEM Kidz Club summer program on a “half day” basis (less than 6 hours) on average ______days per week.
Please initial next to each item that you agree to. Sign at the bottom of the page indicating that you read through each statement.
______I understand that PEM Kidz Club summer SACC program staff will not release my child to anyone NOT listed on this form. No exceptions to this will be made.
______I hereby authorize my child/children to participate in off-site activities within the Plainview community (such as public library, city parks, etc) under the proper supervision by PEM Clubhouse staff. I also give my consent to allow pictures taken, during PEM Clubhouse activities, of my child/children by the news media and/or the program staff to go on the websites or paper.
______I hereby authorize the Staff and/or Program Coordinator, representing PEM Kidz Club summer SACC program, to give consent for any or all necessary emergency medical and First Aid care for my child while my child/children is attending PEM Kidz Club. I understand that I will be responsible for all medical expenses (i.e. hospital, clinic charges).
______I give permission to the PEM Kidz Club summer SACC program staff to provide application of sunscreen lotions and/or insect repellent as needed (Off, Vanilla Spray, etc).
ENROLLMENT AGREEMENT:
I have read the program rules/regulations as outlined above have read the handbook and understand these expectations. I agree to the PEM Kidz Club summer SACC program rates, invoicing and attendance calendar submission procedures and understand that failing to follow these procedures may result in my child’s dismissal from the program. *In an effort to go paperless we will not be printing off Hanbooks unless requested. They will be available on our website
______
Parent’s/Guardian’s Signature Date
PARTICIPATION FEES – cover snacks, swimming pool activities, field trips, etc.
All-inclusive daily rates include all routine program fees such as snacks (when your child is in attendance during regularly scheduled snack times), as well as activity fees for scheduled swimming pool activities, and field trips. See Parent’s Handbook for additional information.
(6 or more hours) / HALF DAY
(less than 6 hours)
One Child / $28.00 per day / $21.00 per day
Two Children / $50.00 per day / $31.00 per day
Three Children / $62.00 per day / $39.00 per day
*There is a 1 day minimum charge per child each week.*
Attendance calendars indicating the days/ times that your child will be present at the PEM Kidz Club summer program must be submitted for the period by the due date indicated below for the participation period. No late calendars will be accepted. Children whose parents fail to submit a calendar by the due date will need to participate at the drop-in rate (as space permits) for the weeks in question.
DROP-IN RATES
Drop in rate will be the regular rate plus $5 per family. Drop-in participants are not eligible for field trips. NOTE: Drop-in participation only available as space permits. You will need to call to see before coming that day.
FIELD TRIPS
For any child to participate in the field trips they must have the permission slips turned in by the deadline for that field trip. When going on field trips your child will have to wear tennis shoes and bring a sack lunch for that day.
Kidz Club will not be open to children not attending field trips on those days.
Permission Slips Due/Field Trip Days are as follows:
June 15th for Big Thrill Factory June 30th
Juley 6th for MN Children’s Museum July 21st
July 27th for Planetarium & Bowlocity August 11th
*Please note that turning in a permission slip you will be billed for your child/ren for a regular day charge whether they attend or not.*
ATTENDANCE CALENDAR &INVOICE PAYMENT DUE DATES
/ PARTICIPATION PERIOD
May 8th Parent Orientation in the Pre-K Media Center / 6pm-7:30pm
*Mandatory for new families*
May 15th / June 5th-16th
June 7th / June 19th-30th
June 21st / July 3rd-14th *Closed July 3rd & 4th*
July 5th / July 17th-28th
July 19th / July 31st-August 11th
August 2nd / August 14th-25th
* Kidz Club will be closed August 28th-September 4th
*You may keep this for your records.* *Please NOTICE it is a different schedule then the school year calendars*