Kid-E-Shack

On-line registration

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1. Parent/Guardian information:

(The fields with asterisks must be filled)

Parent #1

Last Name* A value is required.Exceeded maximum number of characters. First Name* A value is required.Exceeded maximum number of characters.
Address City
State Minimum number of characters not met.Exceeded maximum number of characters. Zip Invalid format.
Home Phone* Invalid format.A value is required. Cell Phone Invalid format.
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License Number
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Parent #2

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Address City
State Minimum number of characters not met.Exceeded maximum number of characters. Zip Invalid format.Invalid format.
Home Phone Invalid format. Cell Phone Invalid format.
Work Phone Invalid format. Email Invalid format.
License Number
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2. Child information:

(Information is required for at least 1 child. The fields with asterisks must be filled)

Child 1

Last Name Exceeded maximum number of characters. First Name* A value is required.Exceeded maximum number of characters.
Birth Date* A value is required.Invalid format. Sex*
Please make a selection.
Hygiene
Food or medical allergy
Take Medication
Asthma
Speech/Communication difficulty
Usually takes nap

Please explain any YES answers from above and any additional information, such as any continuous, long term prescriptions, serious injuries, illnesses, hospitalizations or any other information our staff should have:

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Child 2

Last Name Exceeded maximum number of characters. First Name Exceeded maximum number of characters.
Birth Date Invalid format. Sex
Hygiene
Food or medical allergy
Take Medication
Asthma
Speech/Communication difficulty
Usually takes nap

Please explain any YES answers from above and any additional information, such as any continuous, long term prescriptions, serious injuries, illnesses, hospitalizations or any other information our staff should have:

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Child 3

Last Name Exceeded maximum number of characters. First Name Exceeded maximum number of characters.
Birth Date Invalid format. Sex
Hygiene
Food or medical allergy
Take Medication
Asthma
Speech/Communication difficulty
Usually takes nap

Please explain any YES answers from above and any additional information, such as any continuous, long term prescriptions, serious injuries, illnesses, hospitalizations or any other information our staff should have:

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Child 4

Last Name Exceeded maximum number of characters. First Name Exceeded maximum number of characters.
Birth Date Invalid format. Sex
Hygiene
Food or medical allergy
Take Medication
Asthma
Speech/Communication difficulty
Usually takes nap

Please explain any YES answers from above and any additional information, such as any continuous, long term prescriptions, serious injuries, illnesses, hospitalizations or any other information our staff should have:

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3. School Information:

My child attends the following school and his/her immunization record is on file at the school and all immunizations, vision/hearing screen are current as required by Family Protective Services.

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In the event of an emergency and I am not unable to be reached, I authorize the following persons to pick up my child/children or be contacted for information:

Name Exceeded maximum number of characters. Relationship to child Exceeded maximum number of characters.
Address Phone Number Invalid format.
Name Exceeded maximum number of characters. Relationship to child Exceeded maximum number of characters.
Address Phone Number Invalid format.

4. Emergency Medical Contacts:

In the event I cannot be reached, to make arrangements for emergency medical attention at the time of illness or accidents, I authorize medical personnel to transport my child to:

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Address
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Address

Kid-E-Shack Lakeway is regulated by Family Protective Services.  The minimum standards policies for child centers and our inspection reports are available for review.  We maintain an open door policy.  Parents may visit and observe our center at any time.   A manager or director is always available to discuss any concerns about the policies and procedures.  If a parent would like to stay in the center with their child, we must have a completed criminal background check on file.  You may contact Texas Department of Family and Protective Services licensing office at (512) 438-3312 Region 7.  The address is 355 Texas Avenue, Round Rock, Texas 78664 or www.dfps.state.tx.us.  To report child abuse or neglect, call 800-252-5400.

5. Consent for Medical Treatment

I give consent for Kid-E-Shack Lakeway to secure any and all necessary emergency medical care for my child. I certify my child is in excellent health and physical condition and has no medical, psychological, physical or mental condition, which has not been disclosed to Kid-E-Shack Lakeway on the registration form.

Parent’s Signature* A value is required.Exceeded maximum number of characters. Date* A value is required.Invalid format.

I, on behalf of myself, my spouse, and each child designated on the registration form (my "child"), hereby waive and release all rights, causes of action and claims against Kid-E-Shack Lakeway, a Texas limited liability company, its managing members, directors, agents, and employees, for any loss, expense, damage or injury suffered by my child during the time my child is visiting Kid- E-Shack including the possible negligence of Kid-E-Shack Lakeway, but excluding gross negligence and intentional misconduct. I understand that the provision of childcare contains risk of injury to persons and damage to property, and that by signing this release I engage Kid-E-Shack Lakeway to provide temporary childcare for my children at my own risk. I have been given an opportunity to inspect the premises of Kid-E-Shack Lakeway and found that it is safe and satisfactory for my child. I also have been given the opportunity to ask questions and obtain answers to my satisfaction regarding any and all aspects of Kid-E-Shack Lakeway and this Release. By signing this Release, I have not relied on any promises or statements made by Kid-E-Shack Lakeway or its employees other than those contained in written information supplied to me by Kid-E-Shack Lakeway. I understand this Release will be kept on file at Kid-E-Shack Lakeway and will continue in effect for this and any future visits my Child may make to Kid-E-Shack Lakeway.
I have read the above carefully and fully understand the content and consequences of this agreement and agree to abide by and be bound by the above policies and procedures and release.

Parent’s Signature* A value is required.Exceeded maximum number of characters. Date* A value is required.Invalid format.