A.L. Lotts ElementaryApplication

P.O. Box 22834

Knoxville, TN 37933-0834

Director: Judy Huth

(865) 640-3108

PLEASE COMPLETE ALL INFORMATION IN FULL.

Incomplete Applications Will Not Be Accepted.

YOU CANNOT PUT SAME AS ABOVE.

School year: / 20____/ 20_____

Child’s Information

First Name / Middle Name / Last Name
Home Phone #
Home Address / Birth Date
City / State / Zip

Father’s Information

First Name / Middle Name / Last Name
Home Phone # / Cell Phone # / E-Mail
Home Address
City / State / Zip
Employer / Work Phone #1 / Work Phone #2
Work E-Mail / Position / Usual Work Hours

Mother’s Information

First Name / Middle Name / Last Name
Home Phone # / Cell Phone # / E-Mail
Home Address
City / State / Zip
Employer / Work Phone #1 / Work Phone #2
Work E-Mail / Position / Usual Work Hours

Doctor’s Information

Child’s Physician / Address / Phone #
Preferred Hospital / Address / Phone #

Emergency Contact (Non- Parent)

First Name / Middle Name / Last Name
Relationship To Child
Address
Home Phone # / Work Phone # / Cell Phone #
School Information
School Name / School Address / School Number
LES / 9320 Westland Dr. / 865-539-8611

If parents are divorced, what are the custody arrangements?* ______

*If custody restrictions are involved, you must include a copy of court paperwork BEFORE KidTime can abide by any court orders.

I give KidTime Inc., and its staff permission to photograph my child.

______Initials

I give KidTime Inc., and its staff permission to photograph my child and use the photographs taken for use online, specifically marketing on the KidTime website and/or Facebook

______Initials

There is a copy of my child’s immunization records on file at AL Lotts Elementaryand I give KidTime, Inc. permission to obtain these records when necessary. This MUST be done in order for your child to enroll.

______Initials

In the event that I cannot be reached in an emergency, I hereby give my permission to the program director or designee to gain emergency medical services including transportation and physician.

______Initials

In the event of an emergency, I hereby give permission to qualified KidTime staff to perform First Aid/CPR within their scope of knowledge.

______Initials

I have seen where KidTime’s program will be located.

______Initials

I have received, read, and understand the Parent Handbook, Emergency Handbook, State Licensing Requirements, Personal Safety Letter, and Parent Orientation. I also agree that the above information is correct.

Parent /Guardian Signature ______

Date ______

KidTime Registration Form
AL Lotts Elementary
Students Name: / Parents Name: / Date:
Kindergarten Program
Teacher’s Name / Start Date
Program / Days Requested
Kindergarten Weekly Program / MONDAY - FRIDAY 2:45-6:00pm
Kindergarten Daily Program
 Kindergarten Hourly Program / Mon Tues Wed Thurs Fri 2:45-6:00pm
Mon Tues Wed Thurs Fri
Primary K-5 Program
Teacher’s Name / Start Date / Grade
Program / Days Requested
Aftercare Weekly Program / MONDAY - FRIDAY 2:45-6:00pm
Aftercare Daily Program / Mon Tue Wed Thu Fri
Aftercare Hourly Program / Mon Tue Wed Thu Fri

I have read and reviewed the above form and by signing state that it correct.

Parent /Guardian Signature ______

Date ______

KidTime, Inc.

P.O. Box 22834

Knoxville, TN 37933

865-640-3108

TRANSPORTATION AND PICK-UP AUTHORIZATION

I, ______the legal guardian/parent of ______authorize the following person(s) to be permitted to pick-up or transport my child from the KidTime program.

NAME Drivers License TELEPHONE #

______

______

______

______

______

______

______

Signature Date

KidTime Student Medical History

Personal Information

Child’s Name / Sex
Male / Female / Date of Birth
/ /
Address
Mother’s Work / Mother’s Cell
Father’s Work / Father’s Cell

Physician Information

General Physician / Phone#
Dentist Name / Phone #

Medical Information

Current Medications / Medication Allergies
Food Allergies / Other Allergies

Current Medical Conditions Check All That Apply

Glasses / ADD / ADHD / Physical Limitations
Diabetes (Type 1) / Asthma / Dyslexia / Heart Murmur
Other:

Emergency Contact (Non- Parent)

First Name / Middle Name / Last Name
Relationship To Child
Address
Home Phone # / Work Phone # / Cell Phone #

Signature: ______Date: ______