This form must be completed in its entirety even if your child has attended Jefferson in the past.

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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? Please note: The Ken-Ton Transportation Department generally requires the same drop-off location all five days of the week.

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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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