KPRegForm Submitted 02-27-03

1 REGISTRATION FORM PLEASE PRINT NEATLY! Registration Paid by: Cash/Check/Charge Date: _____ KidsPark Receipt # _____ First Name Initial First Name Initial Last Name (name used to identify your account) Last Name Home Phone Work Home Phone Work Cell Pager Cell Pager Address Address City State Zip City State Zip Driver License # Pass Word Relationship to Child/Children E-mail First Name Last Name First Name Initial Phone # Relationship to Child Last Name First Name Last Name Home Phone Work Phone # Relationship to Child Cell Pager First Name Last Name License # Phone # Relationship to Child Note.

2 A copy of this form will be made and kept on file for every registered child in the family. First Name Last Name Birth Date Sex (Please Circle) Male Female Male Female Male Female Hygiene (Please Circle) In Diapers Training Trained In Diapers Training Trained In Diapers Training Trained Dietary Restrictions 1. Food Allergies? Yes No Yes No Yes No 2. Other Dietary Restrictions: Yes No Yes No Yes No Medical 3. Medicine Allergies? Yes No Yes No Yes No 4.

3 Insect Bite Allergies? Yes No Yes No Yes No 5. Other Allergies? Yes No Yes No Yes No 6. Heart or Lung Condition Yes No Yes No Yes No 7. Asthma? Yes No Yes No Yes No 8. Hearing/Vision Problems? Yes No Yes No Yes No 9. Past Health Problems Yes No Yes No Yes No 10. Diabetes Yes No Yes No Yes No Other: 11. Activity Restrictions? Yes No Yes No Yes No 12. Special Routines? Yes No Yes No Yes No 13. Usually Take a Nap?

4 Yes No Yes No Yes No 14. Speech/Comm. difficulty Yes No Yes No Yes No problems Yes No Yes No Yes No 16. Will a child need to take any prescription or non-prescription medication during their time at KidsPark? If yes, is there a signed permission form on file at KidsPark Yes Yes No No Yes Yes No No Yes Yes No No Please explain any Yes answers, listed by Child s name and question number (attach additional page if necessary): Secondary Guardian 3.

5 Child Information 1. Primary Parent/Guardian 2. Alternative Contact (other than Parent) - Required Other People Authorized for Pick-up 4. Immunization Information I attest that immunizations are current or are in progress for my child(ren). I attest, under penalty of perjury, that to the best of my knowledge, the information is true and correct: Print the First and Last Name of the person completing this section of the form: First Last Relationship to the Child/Youth: Signature of person completing this section of the form: Date Signed 5.

6 Child Emergency Information Doctor s Name Doctor s Address: Doctor s Tel #: Dentist s Name Dentist s Address Dentist s Tel # Hospital preference in the event of emergency: Or closest hospital (Circle choice) Yes No Signature (required) Date ADMISSION FORM agreement On behalf of myself, my spouse, and each child designated (my Child ) I enter into this Admission Form agreement ( agreement ) with Swan Corporation, a Kansas Corporation, dba KidsPark, (hereinafter referred to as KidsPark ), regarding the provision by KidsPark of a supervised, indoor play environment for my Child(ren) *_____.

7 1. Facility Use: Subject to this agreement and other terms as drop-in, short-term child care for my Child on a flexible time basis that includes use of facilities and participation in art and play activities. KidsPark does not take field trips, or provide transportation. I understand that KidsPark does not guarantee that there will be a space for my child to be admitted for care when I arrive at the center. 2. Future Visits: This agreement , the Registration Form and the Release will be kept on file at KidsPark and still continue to constitute binding obligations for any future visits my Child may make to KidsPark.

8 However, this agreement does not obligate KidsPark to continue to provide services and KidsPark reserves the right to refuse admission to any child for any reason without liability. 3. Payment: Payment for KidsPark services will be due at the time of each check-out in cash, charge, or debit card in the amount calculated by multiplying the time elapsed from check-in to check-out by the rates posted at the time of the visit, and for posted amounts for other services, such as meals and retail items. KidsPark may refuse to accept payment by check, and may charge a fee in the amount prescribed at the time of visit for each returned check.

9 No refunds are given. Any changes in fees will be posted for at least 30 days. 4. Health Policies: a) Health: My Child is in excellent health and physical condition and has no medical, psychological, physical, or mental condition which has not been disclosed to KidsPark on the attached Registration Form. My Child does not have any infectious, contagious, or communicable diseases. I understand that I am required to provide a completed signed copy of KDHE Medical Record and Child Health Assessment form to KidsPark as part of this registration and admission agreement if my child, under the age of 6 years, visits 10 or more times in a 30 day period.

10 I further understand that I may transfer this form to KidsPark from another regulated child care facility in Kansas. I also understand that it is acceptable for me to submit a School Health Assessment From for school age children. b) Illness: In the event that my Child becomes sick with a contagious illness after visiting KidsPark and the visit to KidsPark occurred during the gestation period of such illness, I agree to notify KidsPark as soon as possible to enable KidsPark, in its discretion, to notify each family of all the children who may have been exposed.