This form must be completed in its entirety even if your child has attended Jefferson in the past. Please print or save the confirmation page, which you will need to officially register and pay for your child to attend Kids Club.

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* 1. Your Child

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* 2. Child's Gender

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* 3. Child's Date of Birth

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

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

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* 6. Child's Primary Address

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* 7. Child's T-Shirt Size

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

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* 9. Primary Parent/Guardian

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* 10. Secondary Parent/Guardian (if applicable)

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

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

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

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

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

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

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* 17. Emergency Care

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

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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?

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

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

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

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?

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

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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?

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

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

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