WIXLIB

KidZone/WRAPRegistration 2021-2022TeacherGradeMale/FemaleChild’s NameDate of BirthParent / Guardian NameAddressCell PhoneHome/Work phone: (mom/guardian)(dad/guardian)Contact Email (required): (mom/guardian) (dad/guardian)Le CenterSchool Attending (mark one):LonsdaleMontgomery*ALL PAST DUE BALANCES MUST BE PAID IN FULL BEFORE YOUR STUDENT CAN RE-ENROLL FOR THE SCHOOL YEAR.RatesK-6 KidZone Registration OptionsLe Center/Montgomery 7/dayBefore School Set 8/dayDrop In (before school) 9/dayAfter School Set 10/dayDrop In (after school) 12/dayEarly Release Care 36/dayNon School Day Care Before School Set Schedule (opens 6:30am)oMark daysMTuWThFAfter School Set Schedule (closes 5:30pm)o Mark days M Tu W Th F Early Release Days (see calendar for dates) Non School Days (see calendar for dates) Drop In Care Only (TBD based on Covid guidelines)oMark:Before SchoolLonsdale 9/day 10/day 7/day 8/day 10/day 36/day*There is a non-refundable 50 registration fee per family.Please use the credit card attached to payCheck included (TCU 2905)After SchoolSet Schedule Option: This schedule MUST be set on consistent days each week. You are committing to this spot for the school year. If a change to thisschedule needs to take place, we will need a two week notice in writing. This form does not guarantee a spot in the KidZone program, you will get aconfirmation email if a spot is available.Drop In Only Option: Drop in care is limited to space available for the day you are requesting care. Request must be made at least 24 hours in advanceand you must get confirmation that space is available before you can send your child that day, there is no guarantee space will be available.PreK Wrap Registration Options School Day Wrap CareHours Include: 8-3 Montgomery 8:05-3:05 LC 8:45-3:45 Lonsdaleo Morning Wrap (days with PreK) check:o Afternoon Wrap (days with PreK) check:Early Drop Off Care (early as 6:30am) check:Late Pick Up Care (late as 5:30pm) check:No School Day Care (days without PreK) check:Wrap RatesMMMMTTTTWWWWTTTTFFFFMTWTFLC / Montgomery LonsdaleSchool Day Wrap CareMorning / Afternoon Wrap 20/day 20/day 9/dayEarly Drop Off 7/dayLate Pick Up 9/day 7/day 36/day 36/dayNo School Day Care*There is a non-refundable 50 registration fee per family.*must be enrolled in a Little Titans PreK program to use wrap around care.Registration age 3.5-5. *Must be a set / consistent schedule each week. Use credit card attached to payCheck included (TCU 2905)Please complete and return this form with the (non refundable) registration fee if you wish to register for the 2021-22 school year program.This form does not guarantee your child a spot, you will be notified upon acceptance into the program. Space is limited. NOTE: programming is subject to change based on updated COVID-19 guidance.

Novel Coronavirus: Community Education is operated by Tri-City United ISD 2905 and is utilizing acceptable health & safetypractices to protect you the public as well as our workers and volunteers. To this extent, we will be following the Center ofDisease Control (CDC) and local health department guidelines with regard to social distancing practices in order to reduce thespread of Novel Coronavirus, or COVID-19. This will require our staff and volunteers to maintain six (6) feet of distance betweenourselves and you, the student, as much as possible. We will also be requiring this same procedure for student-to-studentcontact in order to limit the exposure to all individuals. We will require all individuals (staff, volunteers, and students) to utilizeeither surgical masks or improvised masks such as scarves, bandanas, and handkerchiefs to reduce the risk of exposure toyourself and others as needed. It is also required of everyone to either wash or sanitize their hands after using the restroom, andtimes when hygiene should be utilized (coughing, sneezing, etc)Bad Weather PolicyIn case of UNPLANNED Early Dismissal (snowstorms, etc.): (Make sure this is the same plan your child’s teacher has)My child(ren) should ride the bus home.My child(ren) should go to KidZone/WRAP. Program will close at 4:00 pm these days, please have arrangements made. An earlierclosing time could be decided if deemed necessary based on the weather.Other:*Weather related late start: KidZone still opens at 6:30am*Snow Days: KidZone is closed if school is closed.*Please refer to parent handbook for other policies. www.tcu2905.us Community Ed KidZoneIs there anything significant about your family situation that you would like us to know? If so, please explain. If there is any court ordereddocument we need a copy of that on file in our office.Name of siblings attending same school:GradeGradeAgeAgeI agree to this contract. I have read the terms and conditions attached and understand that I am responsible for any charges that are incurredbased upon the option that I have chosen for my child. I understand that KidZone is a pay ahead program and that attendance for my child maybe suspended if my account becomes past due. By signing I also acknowledge that my child’s school records can be shared with TCU KidZonestaff as needed. This includes but is not limited to IEP’s, behavior plans, medical records, etc.Parent printed name:Parent Signature:Date:*KidZone/WRAP is not designed to provide 1:1 assistance for children. If a child needs 1:1 student support as described in an IEP, KidZonemust have a meeting with the family and Special Ed team prior to the start date in order to determine the appropriate level of support needed.Information regarding a student’s needs will not be used to prohibit a child’s enrollment in KidZone, unless it is determined they will needsignificant assistance beyond our program capabilities.

Tri-City United Schools, ISD #2905101 2nd Street N.E.Montgomery, MN 56069PHONE 507.364-8100 FAX 507.364.8103RELEASE/CONTRACTChild(ren)’s Name(s)1) Late Fee: I understand that my children may not arrive until 6:30am. The program closes at 5:30pm. Parents will be charged a late fee of 1.00 for everyminute the child is in attendance past closing time. Time to be determined by supervisor. Care may be terminated for multiple late pick-ups.2) Authorized Pick-Up: Any persons authorized to pick up your child must be listed on the Emergency Card. Staff will not allow your child to leave theprogram with an unauthorized person (i.e., a person not listed on the Emergency Card). Your written permission (dated and signed) must be given to the sitesupervisor if you wish to add an authorized person. Staff may be required to ask for photo identification from any newly authorized person with whom staff isunfamiliar. If the person arriving to pick up your child appears to be under the influence of drugs or alcohol, for the child’s safety, staff will contact police.3) Behavior Expectations: Significant disruptive behavior will not be tolerated and will result in termination of KidZone enrollment as per Discipline Policy(see parent handbook).4) Schedule changes: I understand I must keep the KidZone Office/Staff informed of any schedule change. If my child is scheduled to attend KidZone afterschool and then is not present at check-in time, staff will use all means necessary to locate my child. In the event a parent cannot be reached to verify child’slocation, police may be called.5) Photographs of Children: I understand that unless requested, in writing, photographs of my child in KidZone activities may be used for promotional oreducational/training purposes for the KidZone - School Age Care program/Wrap care program.6) Movie Permission: I understand that my child may occasionally view G or (pre-viewed) PG rated movies.7) Shared Information: I understand there may be times when KidZone staff may share information about my child with other departments of the school (i.e.principal, social worker, special ed). This will happen only when it is felt necessary by either party to benefit my child.8) Fees: I understand that KidZone accounts work like school lunch accounts and PREPAYMENT is required. If fees are not paid promptly I understand thatmy child(ren)’s enrollment may be terminated.9) Medical: Parents are expected to transport their own children from school to home or from school to doctor’s office except in cases of dire emergency. Inthe event of an accident or acute illness, school staff shall attempt to notify the parents first. If neither the parent or the emergency contacts can be reached, theschool officials are hereby authorized to take whatever action, including use of an ambulance, if deemed necessary in their judgment for the health and safety ofthe child.10) Medication: All medication will be dispensed as per school district policy.11) Program: I agree to abide by the terms and conditions of KidZone as outlined.12) Bathroom: I understand that my child does need to be fully potty-trained and able to use the school bathrooms unassisted.Signer’s Printed NameParent/Guardian Signature

KidZone/WRAP 2021-2022Tri-City United Public Schools (ISD 2905) Community EducationEMERGENCY * MEDICAL * AUTHORIZATION * RELEASE CARDChild’s Name: School:Birthdate: Grade (21-22 School Year):Parents/Guardians:1. Hm#( ) Wk#( ) Cell#( )2. Hm#( ) Wk#( ) Cell#( )Hospital Preferences: Insurance Carrier:Emergency contact persons if you cannot be reached: (ONE PERSON MUST BE LOCAL)1. Relationship: Phone:2. Relationship: Phone:Name of person(s) NOT authorized to take the childfrom KidZone/WRAP Program*:1. Relationship:2. Relationship:*Court Documentation may need to be providedName of person(s) authorized to take the child fromKidZone /WRAP Program:1. Relationship:2. Relationship:3. Relationship:4. Relationship:

Automatic Payment Plan Agreement (REQUIRED)I hereby give authority for Tri City United KidZone Child Care Program to charge my credit card formy KidZone/WRAP payments. Payments will either be set up as a monthly or bi-monthly charge. Iunderstand any additional fees incurred during the month will be also be charged to my credit card onthat month or the subsequent month. Any credit card changes will require a new form.Child(rens) Name(s)Parent/Guardian NamesAddressPhone NumberVISA / MASTER CARD / DISCOVER / AMEX (please circle)Expiration Date:*This form will be shredded once the payment account has been set up.Please mark which option you would like to be set up with:Monthly (charges will be set for the 5th of each month)Bi-Monthly (charges will be set for the 5th and 20th of each month)SHOULD I DECIDE TO TERMINATE THIS AGREEEMENT OR WITHDRAW MY CHILD(REN) FROM THE PROGRAM, I AGREE TONOTIFY KIDZONE IN WRITING GIVING TWO WEEKS NOTICE. AFTER RECEIPT OF WRITTEN NOTIFICATION, KIDZONE WILLEND THE PRE-AUTHORIZED CHARGES AGAINST MY ACCOUNT. KIDZONE RESERVES THE RIGHT TO TERMINATE THISAGREEMENT SHOULD THE AUTHORIZED CHARGE TO MY CREDIT CARD ACCOUNT BE DECLINED AFTER TWOCONSECUTIVE ATTEMPTS AND MY CHILD WILL BE SUSPENDED FROM THE PROGRAM.Parent/Guardian / Cardholder’s Signature:Date: