Jefferson Kids Club 2020-21 Member Pre-Registration Survey

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* 1. Your Child

Child's First Name

Child's Last Name

Child's Preferred Name (if different)

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* 2. Child's Gender

Male

Female

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* 3. Child's Date of Birth

Month (MM)

Day (DD)

Year (YYYY)

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* 4. Child's Incoming Grade (as of September 2020)

Pre-K

Other (please specify)

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* 5. Child's School (as of September 2020)

Edison Elementary

Franklin Elementary

Franklin Middle

Holmes Elementary

Hoover Elementary

Hoover Middle

Lindbergh Elementary

St. Amelia

St. John the Baptist

St. Christopher

Charter School for Applied Technologies

Glendale Elementary

Stanley G Falk

Other (please specify)

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* 6. Child's Primary Address

Address

City/Town

State

Zip

Phone Number

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* 7. Child's T-Shirt Size

Youth Small

Youth Medium

Youth Large

Adult Small

Adult Medium

Adult Large

Adult XL

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* 8. Who resides in the household where the child lives? Check all that apply.

Mother

Father

Guardian

Grandparent

Sibling

Other (please specify)

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* 9. Primary Parent/Guardian

First Name

Last Name

Address

City/Town

State

Zip

Cell Phone Number

Email Address

Employer

Work Phone Number

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* 10. Secondary Parent/Guardian (if applicable)

First Name

Last Name

Address

City/Town

State

Zip

Cell Phone Number

Email Address

Employer

Work Phone Number

Please list AT LEAST two people (other than the parent/guardians listed above) to contact in case of an emergency if a parent
cannot be reached. These individuals will also be authorized to pick-up your child.

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* 11. Emergency Contact / Authorized Person To Pick Up My Child #1

First Name

Last Name

Relationship to Child

Phone Number

Alternate Phone Number

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* 12. Emergency Contact / Authorized Person To Pick Up My Child #2

First Name

Last Name

Relationship to Child

Phone Number

Alternate Phone Number

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* 13. Emergency Contact / Authorized Person To Pick Up My Child #3 (optional)

First Name

Last Name

Relationship to Child

Phone Number

Alternate Phone Number

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* 14. Emergency Contact / Authorized Person To Pick Up My Child #4 (optional)

First Name

Last Name

Relationship to Child

Phone Number

Alternate Phone Number

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* 15. Emergency Contact / Authorized Person To Pick Up My Child #5 (optional)

First Name

Last Name

Relationship to Child

Phone Number

Alternate Phone Number

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* 16. Emergency Contact / Authorized Person To Pick Up My Child #6 (optional)

First Name

Last Name

Relationship to Child

Phone Number

Alternate Phone Number

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* 17. Emergency Care

Physician Name

Physician Phone Number

Dentist Name

Dentist Phone Number

Preferred Hospital

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* 18. Does your child require staff supervision at more than a 10:1 ratio to safely participate in our program?

Yes

If yes, please explain

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* 19. Does your child receive special services (IEP, 504, Speech, OT, PT) in any other settings (school, home, other) currently or in the past?

Yes

If yes, please explain

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* 20. Will your child be able to transition successfully between activities and participate in group play?

Yes

If no, please explain

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* 21. Please select any allergies or food allergies/restrictions your child has? (i.e.- peanut allergy, vegetarian, etc.)

None

Vegetarian

Vegan

Gluten Free

Nut Allergy

Dairy Allergy

Bee Stings

Other

Please explain what allergy and what actions to be taken in event of an allergic reaction:

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* 22. Does your child take any medications or have any medical conditions we should be aware of?

Yes

If yes, please explain

We do not have a nurse on staff during the school year. Any medications your child will need at the JYC must be kept in their backpack and be self-administered.

Children with allergies, seizure disorders, diabetes, or any other chronic health condition must submit a current action plan to the JYC to have on file, in case of emergency.

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* 23. Please let us know about any recent surgery or serious injury (type & date)

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* 24. Chronic or recurring illness, condition, or diet

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* 25. Does your child have any restrictions on activity?

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* 26. Is there other information that our staff should be aware of that would make your child's experience at Kids Club successful?

Yes

If yes, please explain

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* 27. What days of the week do you anticipate your child attending Jefferson?

Monday

Tuesday

Wednesday

Thursday

Friday

Early release/half days

School breaks

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* 28. What time do you anticipate picking your child up in the evening?

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* 29. Has your child participated in a program like this before?

Yes

If yes, please explain reason for leaving

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* 30. How did you hear about Jefferson Kids Club?

Family member/friend

TTYPR website

Social media

Flyer from school/school district referral

TTYPR e-newsletter

Live nearby

Newspaper

Have attended in the past

Other (please specify)

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* 31. What are the top factors influencing your decision to send your child to Kids Club?

Cost

Location

Activities (field trips, enrichment activities, sports, etc.)

Hours

His/her friends attend

Other (please specify)