Parent Form

Student Section

First Name *

Last Name *

Age *

Grade *

Gender *

Public School Name *

KU site *

Student School ID *

DOB *

Ethnicity *

Home Address *

Apt Number *

Write NA if not applicable

City *

Zip Code *

Free Lunch *

Participated in the Kids-U Program before? *

Parent 1

First Name *

Last Name *

Relationship *

Home Phone *

Work Phone *

Cell Phone *

Email *

Address *

Number of Family members in the home *

Parent 2 (Optional)

Fill NA if not applicable

First Name *

Last Name *

Relationship *

Home Phone *

Work Phone *

Cell Phone *

Email *

Address *

Emergency Contacts

Name of two adults below, other than parent/guardian to contact in case of emergency and have permission to pick up:

Emergency Contact 1

First Name *

Last Name *

Relationship *

Home Phone *

Work Phone *

Email *

Emergency Contact 2

First Name *

Last Name *

Relationship *

Home Phone *

Work Phone *

Email *

Parent Orientation attended *

Annual Income *

Parent Consent Form: I am the parent/legal guardian of the child named above and I give permission for my child to attend and participate in all activities of Kids-U. I hereby release Kids-U, its staff, and volunteers of any liability in the event of accident or injury, and I indemnify them for any liable claims that arise against them from such activities. I allow my child to attend and be transported to any special events or field trips. I understand that I will be notified of events’ time, date and place prior to the event. I understand the Kids-U program is not a licensed childcare program. Parents/ guardians may contact the local state licensing department at (214)951-7902 with any questions. To report suspected child abuse or neglect, call (800)252-5400. More information about childcare licensing can be found online at http://www.tdprs.state.tx.us.

Print Full Name *

Date *

Kids-U does not discriminate based on race, color, religion, sexual orientation, military discharge, sex, national origin, age, disability, or any other characteristic unrelated to the ability to perform the essential functions or basic tenets of Kids-U, or any bona fide occupational qualifications. Kids-U program is not a licensed childcare facility program.

Permissions

Field trip permission *

My child has permission to attend field trips scheduled with Kids-U.Field trip notices will be posted at least 48 hours in advance of each field trip.

Print Initials:

Public school permission *

I hereby give my consent for the Agents of Kids-U/Kids-U staff to communicate directly with my child teacher(s) in an effort to better assist my child with his/her academic success. I also hereby give Kids-U/Kids-U staff permission to obtain all grades for the above-mentioned student as well as TAKS test scores.

Print Initials:

Photo/name Release Permission *

I consent and agree that Kids-U, through their respective employees, directors, officers, contractors, and agents have the right to photograph, record, and/or use my child’s name, likeness, voice, image, and/or photographs and publish, produce, edit, exhibit, copy, and distribute materials containing my child’s name, likeness, voice, image, and/or photographs, whether in print, video, audio, electronic, Internet, and/or digital formats, for any purpose related to promoting and furthering Kids-U’s mission and promoting organizations funded by Kids-U.

I am giving my unrestricted and irrevocable consent and authorization, and I understand and agree that I will not receive any monetary or other compensation now or in the future.

Print Initials:

Medical Permission *

I am the parent and legal guardian of the Agents of Kids-U, have my permission to act only on my behalf in consenting to emergency medical treatment that may be required while my child listed above is in their care. I release Kids-U and its agents from liability for any actions taken in good faith while my child/children listed above are in their care. This includes, but is not limited to, while the child/children are on their property or riding on the van/bus while going to or returning from special events or field trips.

Print Initials*

Walk Home Permission *

My child has permission to walk home from Kids-U which is located in the apartment community.

Print Initials:

Any medical conditions the child has *

Please list any special problems or special cares needs which may pertain to your child. This includes but is not limited to, allergies, existing illness, previous serious illness and injuries, hospitalizations during the past 12 months, and any medications prescribed for continuous long-term use

My student has no allergies or medical conditions
Yes, my student does have the following medical/allergy conditions:

KIDS-U DOES NOT ADMINISTER MEDICATION. ADDITIONALLY IT IS THE PARENT OR GUARDIAN’S RESPONSIBILITY TO ADVISE KIDS-U OF ANY CHANGES IN MEDICATION FOR A CHILD. KIDS-U WILL ALWAYS INFORM HEALTH CARE AND OTHER EMERGENCY PROFESSIONALS THAT THE MEDICATION AND MEDICAL HISTORY INFORMATION IN ITS FILES ARE NOT CURRENT AND THAT A GUARDIAN OR PARENT SHALL BE CONSULTED FOR CURRENT INFORMATION ON THESE SUBJECTS.

Students’ Doctor or Medical Care Facility:
Doctor's Name *

Doctor's Address *

Doctor's Phone Number *

If child does not have physician, put in NA in box.

(No medications will be administered by staff of Kids-U, however parent and/or/guardians are welcome to come and give their child medication.)

Medical/Immunization Records

My student’s medical and immunization records are current and are on file at the public school he/she attends.

Print Initials *

Name of School * School Address * School's Phone Number *

FIELD TRIP & WATER ACTIVITY PARTICIPATION

I am the parent/guardian of a student at Kids-U Afterschool Tutoring & Summer Programs.

I give my permission for my son/daughter to participate in the field trips at Kids-U. My student has no allergies or medical conditions
I give my permission for my son/daughter to participate in water activities at Kids-U including swimming/water sliding/sprinkler play.

I understand that although the students will be supervised by Kids-U staff, I do assume the risk in my student’s participation in the events. If I choose not to permit my child to participate in the field trip or water activities, the student will not attend Kids-U on the day of the events.

I acknowledge that I will not seek to have Kids-U held liable in the event that any accident, injury, loss of property or any other circumstance or incident occurs during or as a result of my son’s/daughter’s participation in the field trip or water activity. This release of liability includes accident, injury, loss, or damages to the student, as well as, to other individuals or property which may result from the student’s participation in the event. I hereby release and agree to hold harmless Kids-U, Kids-U, its officials, agents and employees, from any claims arising out of my son’s/daughter’s participation in the event(s).

I have read and understand and accept all of the statements recited above and accept full responsibility as described.
I acknowledge and give permission for all that I have initialed above.

Print Initials to indicate that you have read and agree to the terms *

Date * Print full name to agree that all of my initials on this form are valid legal signature *

Please read the Parent Handbook below to continue *
Parent Handbook

Check here to indicate that you have read and understood the Parent Handbook

Acknowledgement

I acknowledge and give permission for all that I have initialed above.
Check here to indicate that you have read and agree to the terms
Date * Date of Admission * Date of Parent Orientation *

Make sure you print this form after completion