Fillable Kids Klub Infants Preschool School Age

Fill Online, Printable, Fillable, Blank Kids Klub Infants Preschool School Age Form

Use Fill to complete blank online OTHERS pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Kids Klub Infants Preschool School Age

On average this form takes 82 minutes to complete

The Kids Klub Infants Preschool School Age form is 16 pages long and contains:

13 signatures
57 check-boxes
248 other fields

Country of origin: OTHERS
File type: PDF

BROWSE OTHERS FORMS

Related forms

INDEPENDENT CONTRACTOR INVOICE
HANDYMAN (CONTRACTOR) INVOICE
Life Skills Checklist
LGTW Transition Planning Tool June 2015
Form 1.: LIST 5 GOALS FOR IN EDUCATION
LIST 3 THINGS YOU CAN START WORKING ON
McCoy Federal Credit Union COMMERCIAL CREDIT CARD APPLICATION
cerfa CERTIFICAT DE CESSION DUN VHICULE DOCCASION (
COMPANY PROFILE Paradigm Transportation Management Group , LLC
6- Sample Health History Questionnaire
Vehicle Service Contract Cancellation Request
VACo Associate Members Program County Connections VACo Website
Postsecondary Enrollment Options (PSEO) Program Notice of Student
PATRON CREDIT REQUEST
BP City Of Fort Wayne Emergency Rental Assistance Program Application FINAL
NORTH CAROLINA STATUTORY SHORT FORM POWER OF ATTORNEY
Collegiate Nebraska Press Association Foundation, Inc. Component of
FastOne DSCR/No Ratio Submission Please fulfill minimum submission
85% LTV DSCR is Here!!
This TransArmor Data Protection and Clover Services Participation

Fill has a huge library of thousands of forms all set up to be filled in easily and signed.

Fill in your chosen form

Sign the form using our drawing tool

Send to someone else to fill in and sign.

find another form

Redo

Arial Font

Arial
Calibri
Roboto
Open Sans

AFont color

AB
A.B
A..B
A...B
A....B

Remove Field

ADD FIELDS

380 S. Raymond Avenue  Pasadena, California 91105  (626) 795-2501  FAX (626) 795-2573

Kids Klub

Child Development Centers

Infants  Preschool  School Age

Dear Parents,

Welcome to Kids Klub Child Development Centers! Enclosed, is a membership application packet containing

important information. At Kids Klub, we ha ve a mutual concern for the well being of your child. These forms will

help us to understand your child better and allow us to provide him/her with the proper care. Please complete and return

them to us as soon as possible along with the non- refundable initiation fee of either $250.00 (weekdays) or $50.00

(evenings & weekends) per child.

Because we are required by the State of California Community Care Licensing Department to have

completed records on all children, we ask that you take the time to fill out the attached documents

completely and accurately.

ONLY COMPLETE APPLICATIONS WILL BE ACCEPTED. IF A REQUIRED DOCUMENT IS MISSING,

YOU WILL BE ASKED TO HANG ON TO THE APPLICATION UNTIL ALL COMPLETED DOCUMENTS

CAN BE HANDED IN TOGETHER WITH INITIATION FEE. **EXCEPTION IS MADE FOR UNBORN

INFANTS TO BE PLACED ON WAITING LIST ONLY

All Children:

 Enrollment Application & Parent Information

 Membership Contract & Payment Method

 Identification and Emergency Information

 Child’s & Parent’s Rights

 Field Trip / Sunscreen / Photo Permission

 Child’s Pre-Admission Health History - Parent Report

 Infant or Child’s Needs Form

Infants & Preschool Only:

 Physician's Report (Top portion completed by parent, bottom portion by pediatrician)

 Proof of current T.B. Test required (18 months & older) - Mantoux test

(A Mantoux TB test is required within one year prior to school entry. Skin results must be read by a

physician or nurse. For infants, the test must be given by 18 months of age.)

School Age (After School & Camp) Only:

 After School Contract OR Camp Registration (NOT INCLUDED IN PACKET)

Physician's Report NOT REQUIRED IF CHILD IS ENROLLED IN A PUBLIC OR

PRIVATE KINDERGARTEN OR ABOVE

For children starting our Evening/Weekend Program: Once your application has been received and is

complete, you may start using us within 24 hours. pending certain circumstances, you may be asked to attend an

Orientation for the Evening / Weekend Program prior to acceptance.

For children starting one of our Weekday Programs: An Orientation is required with you to discuss any

particular needs your child may have. An appointment will be made for your family 1-3 weeks prior to your start

date and be prepared to pay for your first month’s tuition at that time. You may start using the Evening/Weekend

program within 24 hours of your complete application being received.

Please retain the last 2 pages of this packet for your records. Copies of other pages in this packet can be made for

you upon request. Please read the Membership Handbook thoroughly to understand all of the Kids Klub Policies &

Procedures. If you have any questions, I will be happy to answer them.

Sincerely,

Vivian Leis, Executive Regional Director

Kids Klub

Child Development Centers

ENROLLMENT APPLICATION

Today's date: ______________

Main Billing Address: ______________________________ ____________________, CA ___________

(Street) (City) (Zip)

Please complete and return the following application form and include $250.00 per child for the non-refundable

initiation fee of weekday members (additional forms and orientation required) or $50.00 per child for

Evening/Weekend members. These fees cover administrative costs for establishing a membership as well as costs

for earthquake kits, mats, sheets, etc. We look forward to being able to meet your childcare needs.

CHILD'S INFORMATION

Shaded area to be filled in by Kids Klub

First Name

Last Name

Birth

Date

Sex

Soc. Sec #

Program

Code

Days of the Week

Lunch

Start Date

M Tu W Th F

Y N

MOTHER'S INFORMATION

Name: _________________________________ Contact Information:

Address: _________________________________ Home: (____) ____ -

(if Different from _____________________, CA Work: (____) ____ -

Billing Address) (City) (Zip) Cell: (____) ____ -

Email: ____________________

Employer: _________________________________

Occupation: _________________________________ Soc. Sec #: _____-_____-_____

Address: _________________________________ Drivers Lic: ________________

_________________________, CA _________

(City) (Zip)

FATHER'S INFORMATION

Name: _________________________________ Contact Information:

Address: _________________________________ Home: (____) ____ -

(if Different from _____________________, CA Work: (____) ____ -

Billing Address) (City) (Zip) Cell: (____) ____ -

Email: ____________________

Employer: _________________________________

Occupation: _________________________________ Soc. Sec #: _____-_____-_____

Address: _________________________________ Drivers Lic: ________________

_________________________, CA _________

(City) (Zip)

School Preference Age Group Services Desired (check all that apply)

 First Available Location  Infant (0 - 2yrs)  Weekday Care

 Pasadena  Preschool (2yrs - Pre-K)  Evening/Weekend Care

 San Gabriel/Rosemead  School Age (Kinder - 8

grade)  Camp (Summer/Winter/Spring)

 *South Pasadena (*DAYTIME SCHOOL AGE PROGRAM ONLY!)

 Check if Existing

Kids Klub Family

Adding a New Child

FORM REQUIRED

FOR ALL CHILDREN

Referred By: ________________________________________________

OFFICE USE ONLY / APPLICATION ACCEPTED BY:

____________________/_________________________/______________

Name / Signature / Date

MEMBERSHIP CONTRACT & PAYMENT METHOD

AGREEMENT TO FOLLOW KIDS KLUB POLICIES

My signature below certifies that I have read, understand and agree to all of the conditions and policies (pre-

admission, Admissions and fees) of a Kids Klub Membership. I understand that Kids Klub reserves the right to

refuse membership or terminate an existing membership to anyone whom does not comply with our Policies as

outlined in the Membership Handbook.

Failure by the provider to enforce one or more terms of the contract does not waive the right of the provider to enforce any other terms of the contract.

________________________

PARENTS NAME PARENT/GUARDIAN SIGNATURE DATE

PAYMENT METHOD

Standard Payment Method:

 Tuition will be paid by check, cash or money order on the 1

of each month. I understand that a late charge

of $25.00 will be added to my account if payment is not received by the 10

of each month. All returned

checks will be charged a $10 returned check fee.

Optional Automatic Withdrawal Payment Method:

If you would like your tuition automatically withdrawn from your checking or credit card each month, please fill

out this section of the application. Your total monthly charges will be deducted on the 3

of the month and you

will receive a statement three week prior detailing your charges and notifying you of the upcoming withdrawal.

We accept MasterCard, Visa & Discover Cards.

 Tuition will automatically be charged to my credit card on the 3

of each month:

(circle applicable credit card type) MasterCard Visa Discover Amex

Card Number:________________________ Expiration Date:_________________ CID: __________

3 OR 4 DIGIT CODE ON BACK

PRINT NAME ON CARD:__________________________________________________

AUTHORIZED SIGNATURE:__________________________________________________

 Tuition will be automatically deducted from my checking account on the 3

of each month.

AUTHORIZED SIGNATURE:___________________________________________________

For office use only:

Initiation Fee Received: $__________________ Date: ____________ Check #: ______

First Payment Received: $__________________ Date: ____________ Check #: ______

ATTACH VOIDED CHECK

OR DEPOSIT SLIP HERE

FORM REQUIRED

FOR ALL CHILDREN

click to sign

signature

click to edit

click to sign

signature

click to edit

click to sign

signature

click to edit

IDENTIFICATION AND EMERGENCY INFORMATION

CONSENT FOR MEDICAL TREATMENT

As the parent, agency representative or legal guardian, I hereby give consent to Kids Klub CDC to seek all

emergency dental or medical care prescribed by a duly licensed Physician (M.D.) Osteopath (D.O.) or Dentist

(DDS) for

_______ This care may be

given under whatever conditions are necessary to preserve the life, limb or well being of my dependent.

Child has the following medication/food allergies: _________________________________

___________________________________________________________________________

PARENT/DOMESTIC PARTNER /GUARDIAN SIGNATURE DATE

PHYSICIAN OR DENTIST TO BE CALLED IN EMERGENCY

PHYSICIAN / DENTIST ADDRESS MEDICAL PLAN AND NUMBER

TELEPHONE

PHYSICIAN / DENTIST ADDRESS MEDICAL PLAN AND NUMBER

TELEPHONE

IF PHYSICIAN CANNOT BE REACHED, WHAT ACTION SHOULD BE TAKEN?

 CALL EMERGENCY HOSPITAL  OTHER EXPLAIN :

NAMES OF PERSONS WHO MAY BE CALLED IN AN EMERGENCY AND

ARE AUTHORIZED TO TAKE CHILD FROM THE FACILITY

(CHILD WILL NOT BE ALLOWED TO LEAVE WITH ANY OTHER PERSON WITHOUT

WRITTEN AUTHORIZATION FROM PARENT OR GUARDIAN)

NAME

RELATIONSHIP

TELEPHONE

Authorized to

Pick up Child on

a Regular Basis

Authorized to Pick

up Child only in

an Emergency

SPECIAL NEEDS / SPECIAL CIRCUMSTANCES

□ No

Does your child have any special needs OR special circumstances that Kids Klub should

be aware of? if Yes, please explain:

Kids Klub Child Development Centers are licensed by the State of California. Some children with special needs

or special circumstances may not be able to be accommodated due to the nature of their individual situation. As

such any child that has a unique need or situation will need to be evaluated to determine if their needs can be met

and that all licensing requirements are met. This applies for both day-time and Evening/Weekend programs.

FORM REQUIRED

FOR ALL CHILDREN

Yes

click to sign

signature

click to edit

CHILD’S & PARENT’S RIGHTS

NOTIFICATION OF CHILD’S PERSONAL RIGHTS AT KIDS KLUB CDC

Personal Rights, Section 101223. Each child receiving services from Kids Klub CDC shall have rights, which includes, but are not

limited to the following:

1. To be accorded dignity in his/ her personal relationship with staff and other persons.

2. To be accorded safe, healthful and comfortable accommodations, furnishing and equipment to meet his/ her needs.

3. To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse,

or other actions of a punitive nature, including but not limited to: Interference with the daily living functions, including eating,

sleeping, or toileting, or withholding of shelter, clothing, medication, or aids to physical functioning.

4. To be informed, and to have the authorized representative informed by the licensee of the provisions of the law regarding

complaints, including, but not limited to, the address and telephone number of the licensing agency’s complaint receiving unit, and

of information regarding confidentiality.

5. To be free to attend religious services or activities of his/ her choice and to have visits from the spiritual advisor of his/her choice.

Attendance at religious services, either in or outside the facility, shall be on completely voluntary basis. In child care facilities,

decisions concerning attendance at religious services or visits from spiritual advisors shall be made by the parent(s), domestic

partner(s), or guardian(s) of the child.

6. Not to be locked in any room, building or facility premise by day or night.

7. Not to be place in restraining device, except a supportive restraint approved in advance by the licensing agency.

I have been personally advised of, and have received a copy of the personal/child’s rights contained in the California Code of

Regulations, Title 22, at the time of admission to KIDS KLUB Child Development Centers, located at 380 S. Raymond Ave., Pasadena,

CA 91105 or 4930 Earle Ave., Rosemead, CA 91770.

X _____________

(CHILD’S NAME) PARENT/DOMESTIC PARTNER /GUARDIAN SIGNATURE (DATE)

NOTIFICATION OF PARENTS’ RIGHTS AT KIDS KLUB CDC

As a Parent/Domestic Partner/Authorized representative, you have the right to:

1. Enter and inspect the child care center without advance notice whenever children are in care.

2. File a complaint against the licensee with the licensing office and review the licensee’s public file kept by the licensing office.

3. Review, at the child care center, reports of licensing visits and substantiated complaints against the licensee made during the last

three years.

4. Complain to the licensing office and inspect the child care center without discrimination or retaliation against you or your child.

5. Request in writing that a parent not be allowed to visit your child or take your child from the child care center, provided you have

shown a certified copy of a court order.

6. Receive from the licensee the name, address and telephone number of the local licensing office.

Department of Social Services, Community Care Licensing Division, Los Angeles Child Care East

1000 Corporate Center Dr. Suite 200-B

Monterey Park, CA 91754

(323) 981-3350

7. Be informed by the licensee, upon request, of the name and type of association to the child care center for any adult who has been

ranted a criminal record exemption, and that the name of the person may also be obtained by contacting the local licensing office.

8. Receive, from the licensee, the Caregiver Background Check Process form.

NOTE: CALIFORNIA STATE LAW PROVIDES THAT THE LICENSEE MAY DENY ACCESS TO THE CHILD CARE

CENTER TO A PARENT/DOMESTIC PARTNER/AUTHORIZED REPRESENTATIVE IF THE BEHAVIOR OF THE

PARENT/DOMESTIC PARTNER/AUTHORIZED REPRESENTATIVE POSES A RISK TO CHILDREN IN CARE.

For the Department of Justic “Registered Sex Offender” database, go to www.meganslaw.ca.gov

I, the parent/domestic partner/authorized representative of the child listed below have received a copy of the “CHILD CARE CENTER

NOTIFICATION OF PARTENTS’ RIGHTS” and the CAREGIVER BACKGROUND CHECK PROCESS form from Kids Klub CDC.

X _____________

(CHILD’S NAME) PARENT/DOMESTIC PARTNER /GUARDIAN SIGNATURE (DATE)

FORM REQUIRED

FOR ALL CHILDREN

click to sign

signature

click to edit

click to sign

signature

click to edit

FIELD TRIP / SUNSCREEN / PHOTO PERMISSION

WALKING FIELD TRIP PERMISION

 I hereby give Kids Klub CDC my consent and permission to take my child from the center

on local walking field trips close to Kids Klub.

 I DECLINE to give Kids Klub CDC my permission for walking field trips.

In either case, you will always be notified of an upcoming remote field trip where the children

will be transported from the center by van, bus or car. For each trip, you will receive details of

the trip, and you will need to give your permission for each trip. Only children with signed

authorizations will be allowed to go on field trips.

X _____________

(CHILD’S NAME) PARENT/DOMESTIC PARTNER /GUARDIAN SIGNATURE (DATE)

SUNSCREEN PERMISSION

 I hereby give the staff of Kids Klub CDC permission to apply sunscreen on my child as

needed. I understand that it is my responsibility to provide sunscreen and keep it in my child’s

cubby. Due to the potential of allergic reactions to certain sunscreens, Kids Klub cannot

provide the sunscreen for me.

 I DECLINE to give Kids Klub CDC my permission for Sunscreen.

X _____________

(CHILD’S NAME) PARENT/DOMESTIC PARTNER /GUARDIAN SIGNATURE (DATE)

PHOTOGRAPIC RELEASE PERMISSION

 Full PhotoPermission: I hereby give Kids Klub CDC permission to use photographs of my child on the photo

boards, website and /or in brochures, etc. I understand that these photographs will not be sold by Kids Klub,

and that my child may appear individually or in a group setting. Other than on our hallway photo boards, the

name of my child will not be published in conjunction with these photographs without additional written

consent from the parent.

 Partial Photo Permission: I hereby give Kids Klub CDC permission to use the photographs of my child for

in house use (photo boards, personal portfolios, holiday gifts) and WiMLO Private (just sent to parent’s of

child only).

 I DECLINE to give Kids Klub CDC my permission for Photographs in any form.

X _____________

(CHILD’S NAME) PARENT/DOMESTIC PARTNER /GUARDIAN SIGNATURE (DATE)

FORM REQUIRED

FOR ALL CHILDREN

WiMLO Private: Any group shots sent to the class parents involving a “private” child will

be blurred out or not include the child. The “private” child’s parents can received either

group shots including the child and/or individual pictures of the “private” child – these will

be sent exclusively to just the child’s parents.

click to sign

signature

click to edit

click to sign

signature

click to edit

click to sign

signature

click to edit

PARENT/DOMESTIC PARTNER /GUARDIAN SIGNATURE

___________________________________________________________________________________________________________

FORM REQUIRED

FOR ALL CHILDREN

click to sign

signature

click to edit

RISK FACTORS FOR TB IN CHILDREN:

* Have a family member or contacts with a history of confirmed or suspected TB.

* Are in foreign-born families and from high-prevalence countries (Asia, Africa, Central and South

America).

* Live in out-of-home placements.

* Have, or are suspected to have, HIV infection.

* Live with an adult with HIV seropositivity.

* Live with an adult who has been incarcerated in the last five years.

* Live among, or are frequently exposed to, individuals who are homeless, migrant farm workers,

users of street drugs, or residents in nursing homes.

* Have abnormalities on chest X-ray suggestive of TB.

* Have clinical evidence of TB.

Kids Klub CDC

6:30 am

to 10:00pm 7 days a week.

REQUIRED FOR ALL

INFANT & PRESCHOOL CHILDREN

NOT REQUIRED FOR SCHOOL AGE CHILDREN

Parent / Domestic Partner / Guardian Signature

click to sign

signature

click to edit

KIDS KLUB INFANT & CHILD’S NEEDS

The purpose of this information is t

o help your caregiver have a better understanding of your child’s history.

The information contained on these pages will aid in planning for your child’s individual needs.

PART A: FOR CHILDREN UNDER 2 YEARS OF AGE – OVER 2 YEARS OLD, PLEASE SKIP TO PART B

INFANT INDIVIDUAL FOOD AND FEEDING PLAN:

We warm formula or breast milk in a bottle warmer. Our care giving staff wants to be able to greet each family and exchange

information as well as check for any illness upon arr

ival.

Breastmilk /type of formula or combination of? ____________________________________________________________.

My child usually has a bottle about every ______________ hours, and takes approximately _____________ ounces.

Is your child on a special diet? YES / NO If yes, please describe _______________________________________________.

Is child on solid foods? YES / NO If yes, please describe ____________________________________________________.

My child is usually COMFORTABLE / UNCOMFORTABLE after eating. If uncomfortable, I usually

___________________________________________________________________________________________________.

My child’s sleep schedule is as follows: ___________________________________________________________________.

My child naps for approximately __________ hours/minutes between _______ & _______ a.m. and _______ & _______p.m.

How does your child get to sleep? ROCKING EATING PACIFIER FUSS A LITTLE?

In what position does he/she sleep best? BACK OR SIDE?

What does child sleep with? _________________________________.

DIAPERING/TOILETING

Does your child have a tendency to get diaper rash? YES NO

If yes, what do you do to alleviate it? ______________________.

What words are used at home in reference to toileting?

Parent’s Signature: _________________________________________________________

Date: _____________

___________________________________________________________.

Director’s Signature:________________________________________________________

PART B FOR CHILDREN OVER 2 YEARS ON SECOND PAGE

Childs Name: ____________________________ Child’s Age: ____________ Today’s Date: ______________

ALLERGIES ONLY: List all Foods / Medications / Environmental allergies–

Has an Epi-Pen been prescribed by a doctor for your Child?: YES NO

If Yes, please tell us what it has been prescribed for: _____________________________________________________

SPECIAL CIRCUMSTANCES: IE. FOOD PREFERENCES / DIETARY RESTRICTIONS, SPECIAL NEEDS,

MEDICAL CONDITIONS, ETC: Please list any foods / drinks that you would like for Kids Klub to avoid feeding your

child. This is for preferences only not allergies, please list any true allergies above:

 Updated in Computer _____ (initials)

 Allergy Paper Work Given to Parents _____ (initials)

FORM REQUIRED

FOR ALL CHILDREN

What are your goals/desires regarding toilet training?

Date: _____________

click to sign

signature

click to edit

eater.

PART B: FOR CHILDREN OVER 2 YEARS OF AGE

Circle one: My child is a: good moderate picky

Are there any special dietary needs? Please Explain:

Has your child had any regular

caregivers outside the immediate family, or any prior group experience? If yes, describe.

Please note any distinguishing

physical and / or emotional characteristics which you feel may affect

your child’s total behavior (e.g. high activity level, sensitive, large for age, tires easily, etc……)

Does your child have any fear

s that we should be aware of? How do you deal with these fears?

Has your child had any serious accidents, serious illnesses, operations, hospitalizations, disabilities, or convulsions? Describe those or

any other pertinent medical facts.

Any major domestic ty

pe of events that may have affected your child?

How does your child relate to strangers?

What makes your child angry or upset?

Does your child nap? YES NO

How long do they normally nap for?___________

Does your child use a pa

cifier, suck their thumb or cling to a blanket? If so, please describe when it is needed.

Is any other language than Engli

sh spoken at home?

If your child has words or sounds t

hat are not commonly used by others, please list their meaning:

Are there any areas of your

child’s speech / language development that concerns you? If so, has it been professionally diagnosed?

Parent’s Signature: _________________________________________________________

Date: _____________

Director’s Signature: ________________________________________________________

PERIODIC UPDATES ON INFANT & CHILD’S NEEDS MAY BE REQUIRED

Childs Name: ____________________________ Child’s Age: ____________ Today’s Date: ______________

FORM REQUIRED

FOR ALL CHILDREN

Date: _____________

PARENT’S INFORMATION PAGES

Parents: Please detach the last 2 pages from this application packet and retain for your records. We are

happy to make copies of any additional pages that you would like to have for your records as well.

NOTIFICATION OF CHILD’S PERSONAL RIGHTS AT KIDS KLUB CDC

Personal Rights, Section 101223. Each child receiving services from Kids Klub CDC shall have rights, which includes, but are not

limited to the following:

8. To be accorded dignity in his/ her personal relationship with staff and other persons.

9. To be accorded safe, healthful and comfortable accommodations, furnishing and equipment to meet his/ her needs.

10. To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse,

or other actions of a punitive nature, including but not limited to: Interference with the daily living functions, including eating,

sleeping, or toileting, or withholding of shelter, clothing, medication, or aids to physical functioning.

11. To be informed, and to have the authorized representative informed by the licensee of the provisions of the law regarding

complaints, including, but not limited to, the address and telephone number of the licensing agency’s complaint receiving unit, and

of information regarding confidentiality.

12. To be free to attend religious services or activities of his/ her choice and to have visits from the spiritual advisor of his/her choice.

Attendance at religious services, either in or outside the facility, shall be on completely voluntary basis. In child care facilities,

decisions concerning attendance at religious services or visits from spiritual advisors shall be made by the parent(s), domestic

partner(s), or guardian(s) of the child.

13. Not to be locked in any room, building or facility premise by day or night.

14. Not to be place in restraining device, except a supportive restraint approved in advance by the licensing agency.