Farragut Primary Application

P.O. Box 22834

Knoxville, TN 37933-0834

Director: Alex Huth

(865) 640-3109

alex@kidtime.org

PLEASE COMPLETE ALL INFORMATION IN FULL.

Incomplete Applications CAN NOT Be Accepted.

Please DO NOT put ‘SAME AS ABOVE’ in any field

School Year: 20 /20
My child has previously attended a KidTime After School Program
Name of Person Completing Application:

Child’s Information

First Name	Middle Name	Last Name
Home Phone # None
Home Address	Birth Date
City	State	Zip

Mother’s Information

Please enter biological parent’s information below. If there is a reason you do not have biological parent information, please check ‘other’ and explain. Other. explain
First Name	Middle Name	Last Name
Home Phone # None	Cell Phone # None	Social Security # Required for identification and billing
Home Address	Personal Email None
City	State	Zip
Employer None	Work Phone #1	Work Phone #2
Work E-Mail None	Position	Usual Work Hours

Father’s Information

Please enter biological parent’s information below. If there is a reason you do not have biological parent information, please check ‘other’ and explain. Other. explain
First Name	Middle Name	Last Name
Home Phone # None	Cell Phone # None	Social Security # Required for identification and billing
Home Address	Personal Email None
City	State	Zip
Employer None	Work Phone #1	Work Phone #2
Work E-Mail None	Position	Usual Work Hours

Billing Information

Invoices should be sent to Father Mother Both Additional costs may apply if cost is to be split between parents (parent initial) “I have read and understand the Fee Payment Schedule in the Parent Handbook. I agree to make regularily scheduled payments or my child may be dismissed from the program.”

Doctor’s Information

Child’s Physician	Phone #	Preferred Hospital
Address
City	State	Zip Code

Emergency Contact (Non- Parent)

First Name	Last Name	Relationship
Home Phone # None	Work Phone # None	Cell Phone # None
Address
City	State	Zip Code

School Information
School	Address	Phone #
Farragut Primary School	509 N. Campbell Station Rd	(865) 966-5848
If parents are divorced, what are the custody arrangements?* *If custody restrictions are involved, you must include a copy of court paperwork BEFORE KidTime can abide by any court orders.
I give KidTime, Inc. and its staff permission to talk to the school about my child. I give KidTime, Inc. and its staff permission to obtain my child’s immunization records, (which are held on file at Farragut Primary School), when necessary. This MUST be done in order for your child to enroll In the event that I cannot be reached in an emergency, I hereby give my permission to the program director or designee to gain emergency medical services including transportation and physician. In the vent of an emergency, I hereby give permission to qualified KidTime staff to perform First Aid/CPR within the scope of their knowledge. I give KidTime Inc., and its staff permission to photograph my child. I give KidTime Inc., and its staff permission to use the photographs on the KidTime website and/or Facebook

I agree that the above information is correct. As my electronic signature, I enter the information below:
The City and State of Birth
The City and State of birth	Today’s Date
Signature or Full Name if using this as an electronic signature

Attendance Form
K - 2nd Grade Program
Teacher’s Name Unavailable at this time	Start Date	Grade
Program	Days Requested
Aftercare Weekly Program Aftercare Daily Program Aftercare Hourly Program Minimum of five (5) hours/ week required	Monday – Friday 2:45-6:00 pm - $75/week Mon Tue Wed Thu Fri - $20/day Mon Tue Wed Thu Fri - $12/hour
In-Service Program
Yes No Require In-service Day Supplement Program
Please check all that apply Currently enrolled sibling Siblings Name Knox County School Teacher Knox County School Employee Specify Child on state certificate – Must provide proof to the site director Scholarship – Must have prior approval from site director. Have had a child attend KidTime in the past (other than the child currently enrolled): Child's Name and Year Enrolled
Important Notes
To change your child’s attendance schedule, please contact your site director Fees are charged according to schedule signed up for, not attendance Daily – one day per week minimum Hourly – five (5) hours per week minimum. Sibling Discount on WEEKLY ONLY – 10% on second child (if billed together)

KidTime Student Medical History

Personal Information
Child’s Name: Male Female
Medical Information
Current Medications None	Medication Allergies None
Food Allergies None	Other Allergies None
Current Medical Conditions
Check all that apply
Glasses ADD ADHD Diabetes (type 1) Asthma Physical Limitations Explain any physical limitations:	Dyslexia Heart Murmur Downs Syndrome* Autism* Asperger Syndrome* Other:
*Please contact the site director for further assistance

Transportation and Pick-Up Authorization
I, , the legal guardian/parent of , authorize the following person(s) to be permitted to pick-up and/or transport my child from the KidTime program.
NAME	DRIVER’S LICENSE #	TELEPHONE #

Information Check List
NOTE: This information will help KidTime provide the best environment for your child.
Enter any custody information in his space None What are some ways in which your child plays at home?
Has your child had any of the following experiences during the past year?
Birth of another child in the family Yes No Changing Schools? Yes No Separation or divorce of parents? Yes No Other:	Moving? Yes No Serious illness of child or family member? Yes No Death in family? Yes No
Would you describe your child as (check all that apply) active quiet friendly Shy
Please list your expectations for KidTime:
Do you want your child to work on academic homework at KidTime? Yes No
Areas to focus attention:

Parent Handbook Checklist
By initialing each item on this checklist the parent/guardian indicates that they understand and will follow guidelines in all handbooks. Questions or concerns about a program policy should be discussed before initialing this list and submitting the application.
Program Dates and Times Fees and Payments Registration Payment Schedule Certificates, discounts, scholarships Forms of Payments Billing Statements / Questions Termination of Services Illness and Sick Child Policy Medication Policy Vacation Policy Inclement Weather Policy In-Service Days In-Service Lunch and Drink Dress Code Dress Code – Gym Shoes Dress Code – Coats	Toys from Home Drop-off and Pick-up Drop-off and Pick-up – Regular School Days Drop-off and Pick-up – Full-Day Care Drop-off and Pick-up – Attendance Info Drop-off and Pick-up – Late Pick-up / Fees Program Content Newsletter Discipline Policy Parent Involvement Confidentiality Emergency Procedures Grievance Policy DHS Requirements Site Before Enrollment

I agree that the above information is correct. As my electronic signature, I enter the information below:
The City and state of my birth
The City and State of birth	Today’s Date
Signature or Full Name if using this as an electronic signature

To Complete the Registration Process
Email the signed and dated registration, to the Farragut Site Director: Alex Huth at alex@kidtime.org