Registration Forms 2024-2025 Registration Form 2024-2025 Registration Forms for Students "*" indicates required fields Step 1 of 7 14% Kids' Advocacy Coalition Registration FormComplete one registration form per child.Is your child new or a returning KAC student?* Returning New to KAC Child's Name* First Middle Last Date of Birth* MM slash DD slash YYYY Race OptionalAge*Please enter a number from 3 to 14.Sex* Male Female School*Annie Belle Clark PrimaryGO Bailey PrimaryLen Lastinger PrimaryNorthside PrimaryJT Reddick ElementaryOmega ElementaryCharles Spencer ElementaryMatt Wilson ElementaryEighth Street MiddleNortheast MiddleGrade*Pre-KKindergarten1st Grade2nd Grade3rd Grade4th Grade5th Grade6th Grade7th Grade8th GradeMailing Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Do you have a second child enrolled at KAC? Yes Name of second child enrolled at KAC* First Last School*Annie Belle Clark PrimaryGO Bailey PrimaryLen Lastinger PrimaryNorthside PrimaryJT Reddick ElementaryOmega ElementaryCharles Spencer ElementaryMatt Wilson ElementaryEighth Street MiddleNortheast MiddleGrade*Pre-KKindergarten1st Grade2nd Grade3rd Grade4th Grade5th Grade6th Grade7th Grade8th GradeDo you have a third child enrolled at KAC Yes Name of third child enrolled at KAC* First Last School*Annie Belle Clark PrimaryGO Bailey PrimaryLen Lastinger PrimaryNorthside PrimaryJT Reddick ElementaryOmega ElementaryCharles Spencer ElementaryMatt Wilson ElementaryEighth Street MiddleNortheast MiddleGrade*Pre-KKindergarten1st Grade2nd Grade3rd Grade4th Grade5th Grade6th Grade7th Grade8th GradeDo you have a fourth child enrolled at KAC Yes Name of fourth child enrolled at KAC* First Last School*Annie Belle Clark PrimaryGO Bailey PrimaryLen Lastinger PrimaryNorthside PrimaryJT Reddick ElementaryOmega ElementaryCharles Spencer ElementaryMatt Wilson ElementaryEighth Street MiddleNortheast MiddleGrade*Pre-KKindergarten1st Grade2nd Grade3rd Grade4th Grade5th Grade6th Grade7th Grade8th GradeIf you have any additional children call the office at (229) 382-9919.Payment InformationPrimary Payer* First Last Relationship to child* Cell Number*Text Reminders* Yes No Mobile Carrier* Verizon AT&T Straight Talk Other Home Address(Only complete, if different than your mailing address.) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Place of Employment* Work Phone*Email Address* Email Reminders* Yes No Emergency Contact* Yes No Authorized Pickup* Yes No Is there a secondary payer for this child?* Yes No Secondary Parent / Guardian InformationSecondary Payer* First Last Relationship to child* Cell Number*Text Reminders* Yes No Mobile Carrier* Verizon Stright Talk AT&T Other Home Address(Complete if different than primary payer) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Place of Employment* Work Phone*Email Address* Email Reminders* Yes No Authorized Pickup* Yes No Emergency Contact* Yes No Other Person(s) Authorized to Pickup Your ChildYou can up to 2 additional persons authorized for pickups.Are Other Persons Authorized to Pickup Your Child?* Yes No 1- Authorize Person to Pickup Child* First Last Phone*Emergency Contact* Yes No Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Relationship to child* Relationship to parent / guardian* 2- Authorize Person to Pickup Child First Last PhoneEmergency Contact Yes No Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Relationship to child Relationship to parent / guardian If additional authorized person to pickup child call our office. Medical Care and Contact InformationHealth Insurance Company Child's Physician or Clinic* Physician or Clinic's Phone*My child has the following needsThe following special accommodation(s) may be required to most effectively meet my child's needs while at the centerMy child is currently on medication(s) prescribed for long-term continuous use and/or has the following pre-existing illness, allergies, or health concernsDailey nutritional snacks are provided all children as part of the program. Does your child have any dietary restrictions?* Yes No Please list all dietary restrictions and allegories:*Medical AuthorizationConsent* If your child suffers an injury or illness while in the care of Kids' Advocacy Coalition and the facility is unable to contact me (us) immediately, it shall be authorized to secure such medical attention and care for the child as may be necessary. I (We) shall assume responsibility for payment for services.Parent/Guardian*This field acts as your authorized signature. Date*Today's Date MM slash DD slash YYYY Parental Agreements with Child Care FacilityChild's Name*The Kids' Advocacy Coalition agrees to provide day care for your child listed here. First Last Is your child served by an IEP?* Yes No FileMax. file size: 512 MB.Please upload copy of the IEP. If you cannot upload a digital file(s), please print and return a copy of your IEP to KAC's office (1815 Chestnut Ave, Tifton, GA 31794.) This must be complete before your child is fully enrolled. Terms Conditions and Agreement* I understand, consent, and agree to the terms and conditions from KAC's after school program, listed here. Terms Conditions and Agreement I understand that I am responsible for a one-time $40 registration fee for each child. I understand that I am responsible for weekly payments of $50.00 for pick up by 4:45, or $60.00 for pick up by 6:00, to be paid by Friday for the week of care or a $5 late fee may be applied. If my child(ren) attends less than 5 days, I will refer to the Weekly Fee Sheet for amount owed. I understand & agree that if I become more than two weeks behind in fee payments, I will be asked to make other arrangements for after school care for my child. If my child becomes a discipline problem while in the after school program, a conference will be arranged between myself and the staff. I agree to adhere to the after school care and enrichment program policies and give my child permission to participate fully in the program. I agree to pick up my child by 6:00 pm. I understand that a late fee of $5.00 will be charged for students picked up from 6:01 pm - 6:15 pm, with an additional $10 for increments of 15 minutes. Parents who are late three times per month will be asked to make other arrangements for after school care. The after-school childcare staff will assume full responsibility for my child from check in time until he/she leaves. The child must check in with the staff and must be signed out daily when he/she is picked up. My child will not be allowed to enter or leave the facility without being escorted by the parent, person authorized by parent, or facility personnel. I acknowledge it is my responsibility to keep my child's records current to reflect any significant changes as they occur, e.g. telephone numbers, work location, emergency contacts, child's physician, child's health status and immunization records, etc. The facility agrees to keep me informed of any incidents, including illnesses, injuries, adverse reactions to medications, etc., which include my child. Before any medication is dispensed to my child, I will provide a written authorization, which includes date, name of child, name of medication, prescription number, if any, dosage, date and time of day medication is to be given. Medicine will be in the original container with my child's name marked on it. I understand that it is my responsibility to provide insurance coverage for my child. The Kids' Advocacy Coalition agrees to obtain written authorization from me before my child participates in routine transportation, field trips, special activities away from the facility, and water related activities occurring in water that is more than two (2) feet deep. The after school child care program is designed to be a flexible program which provides safe and appropriate care for a group of elementary and middle school students of varying ages and abilities while the parents are at work or in school. If, after a trial period, the program is unable to successfully meet the needs of any child, it may be deemed necessary for the child to be cared for in a setting which is appropriate for his/her needs. This decision will only be made after considering input from the parents, the staff, and/or any specialist whose expertise would be beneficial. I authorize the childcare facility to obtain emergency medical care for my child when I am not available. I have received a copy and agree to abide by the policies and procedures for Kids' Advocacy Coalition. I understand the facility will advise me of my child's progress and issues relating to my child's care as well as any individual practices concerning my child's special needs. Media Release I give permission for my child to appear in any media coverage approved by the after school program. I understand that the Director in conjunction with KAC will determine the appropriate requests. Parent/Guardian Notice of No Liability Insurance and AcknowlegementI understand* I understand and agree by signing below and that this child care facility does not carry liability insurance sufficient to protect my child(ren) in the event of an injury, etc.Parents'/Guardians' Signature(s)* By typing your name, this acts as your signature. Authorization to Dispense External Preparations 590-1-1-.20 (1)Parental Authorization* Except for first aid, personnel shall not dispense prescription or non-prescription medications to a child without specific written authorization from the child's physician or parent. Such authorization will include, when applicable, date; full name of the child; name of the medication; prescription number, if any; dosage; the dates to be given; the time of day to be dispensed; and signature of parentPermissionI give Kids' Advocacy Coalition, permission to apply one or more of the following topical ointments/preparations to my child in accordance with the directions on the label of the container: Baby Wipes Baby Powder Band-aids Neosporin or similar ointment Bactine or similar first aid spray Sunscreen Insect Repellent Non-Prescription ointment (such as A & D, Destine, Vaseline Parental or Guardian Name*By typing your name here, this acts as your signature. Date*Today's Date MM slash DD slash YYYY CAPTCHAEmailThis field is for validation purposes and should be left unchanged.
