Childcare Only FormPlease enable JavaScript in your browser to complete this form.12345Parent InformationFatherStep-FatherGuardianName *FirstLastAddress *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone *Email *Parent InformationMotherStep-MotherGuardianName *FirstLastAddress *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone *Email *With Whom Does the Child Live? *Both ParentsShared CustodyMotherFatherOtherWithout a court-ordered custody agreement, child(ren) may be released to either parent at any time. Who is Responsible for Tution? *NextStudent InformationIf your child has an IEP or 504 plan, copies must be provided and reviewed by the administration before admissions. Name of Child *FirstLastDate of Birth *Gender *MaleFemalePlease Indicate which Room your Child will be in:Infants (6 weeks-1 year old)Waddler (1-2 years old)Toddler (2-3 years old)Childcare OnlyEthnicity *Asian AmericanAmerican Indian/Alaska NativeAfrican American or BlackHispanic or LatinoNative AmericanWhiteNextExcel in GivingExcel In Giving Forms will need to be completed.Please check which payment plan you intend on using: *9 Months12 MonthsName of School District in which Student(s) Resides: *Name of School/Daycare Student Previously Attended: *Any Learning, Health or Physical Disabilities that should be known? (Please Include any Allergies or Medical Conditions)Do you Attend Church? *YesNoName of Church Currently Attending:Has the Child(ren) been Baptized? *YesNoNextParental ConsentsPhoto AgreementI grant permission for my child(ren) to be included in any photos or videotapes the school may use for school bulletin boards, newsletters, yearbooks, web pages, promotions, class projects, etc. Furthermore, I consent that such photographs and or videos shall be the property of St. Michael Lutheran School and Christ for Kids (SMLS/CFK), which has the right to duplicate, reproduce, and make other appropriate uses as SMLS/CFK deems necessary.Parent's Printed Name *Parent's Signature * Clear Signature School Directory AgreementI grant permission for my family and child(ren)’s name, address, phone number to be used for church and school business, and to be included in a Parent Directory that will be made available to all St. Michael Lutheran School and Church families. The information in the directory may not be used for promotional, business, or political mailings or phone calls. It is intended solely for the convenience and information of SMLS/CFK families.Parent's Printed Name *Parent's Signature * Clear Signature Non-Refundable Registration FeeI understand the registration fee is non-refundable and that the registration fee is due with this form.Parent's Printed Name *Parent's Signature * Clear Signature HealthI affirm that to the best of my knowledge, my child(ren) is in good physical health to attend SMLS/CFK. I acknowledge that SMLS/CFK will take due diligence with the health and safety of my child(ren) and I will not hold SMLS or CFK liable for any event relating to any preexisting medical conditions, disclosed or undisclosed.Parent's Printed Name *Parent's Signature * Clear Signature Diaper Rash CreamI give per mission to the staff at Christ for Kids to apply diaper rash cream (provided from home) whenever it is needed to my child throughout the day. Parent's Printed Name *Parent's Signature * Clear Signature NextChildcare NeedsPlease note when you anticipate needing care - we understand your schedule may change.StudentIndicate Typical Days and Times for Drop Off/After School A Note about Call Ahead and Drop In Childcare:Christ for Kids strives to be flexible with scheduling policies. However, to ensure proper staffing we request that families call ahead when additional care is needed. Should space not be available, we reserve the right to refuse care to students who have not prescheduled their attendance.Submit99329
