Preschool & Kid Camp Sign Ups

ThorntonParksLogo

Registration Information

Youth Info

Youths Name

Home Phone Number

Date of Birth

Gender

Male Female

Hair Color

Eye Color

Home Address

Address Line

Address Line 2

City

State

Zip

Guardian Info

Guardians Name

Address (if different than youth's)

Address Line

Address Line 2

City

State

Zip

Place of Employment

Guardians Email

Work Phone Number

Place of Employment Address

Address Line

Address Line 2

City

State

Zip

Guardian Info

Guardians Name

Address (if different than youth's)

Address Line

Address Line 2

City

State

Zip

Place of Employment

Guardians Email

Work Phone Number

Place of Employment Address

Address Line

Address Line 2

City

State

Zip

Person's Authororized to Pick Up Youth

(Please include self)

Pick-Up Person Info

Pick-Up Person Name

Pick-Up Person Phone Number

Pick-Up Person Work/Alternate Phone Number

Relationship to Participant

Pick-Up Person Address

Address Line

Address Line 2

City

State

Zip

Pick-Up Person Info

Pick-Up Person Name

Pick-Up Person Phone Number

Pick-Up Person Work/Alternate Phone Number

Relationship to Participant

Pick-Up Person Address

Address Line

Address Line 2

City

State

Zip

Pick-Up Person Info

Pick-Up Person Name

Pick-Up Person Phone Number

Pick-Up Person Work/Alternate Phone Number

Relationship to Participant

Pick-Up Person Address

Address Line

Address Line 2

City

State

Zip

Emergency Contacts to call if guardian cannot be reached and medical authorization may be obtained

Emergency Contact Info

Emergency Contact Name

Emergency Contact Cell Phone Number

Emergency Contact Relationship

Emergency Contact Work Phone Number

Emergency Contact Address

Address Line

Address Line 2

City

State

Zip

Emergency Contact Info

Emergency Contact Name

Emergency Contact Cell Phone Number

Emergency Contact Relationship

Emergency Contact Work Phone Number

Emergency Contact Address

Address Line

Address Line 2

City

State

Zip

Emergency Contact Info

Emergency Contact Name

Emergency Contact Cell Phone Number

Emergency Contact Relationship

Emergency Contact Work Phone Number

Emergency Contact Address

Address Line

Address Line 2

City

State

Zip

Medical Information

Doctor Info

Doctors Name

Doctors Phone Number

Doctors Address

Address Line

Address Line 2

City

State

Zip

Dentist Info

Dentists Name

Dentists Phone Number

Dentists Address

Address Line

Address Line 2

City

State

Zip

Youths Insurance Provider

Group Number

ID Number

Hospital Preference

Preferred Hospital Address

Address Line

Address Line 2

City

State

Zip

Any Allergies or Health Problems We Need To Be Aware Of

Special Instructions

Emergency Medical Authorization

I, , hereby give permission to the City of Thornton Staff to call a doctor for medical or surgical care for my youth, , should an emergency situation arise. It is understood that a conscious effort will be made to locate my spouse or me before any action will be taken, but if it is not possible to locate us, this expense will be expected by us.

I understand that it is my responsibilty to apply sunscreen to my youth before bring him/her to camp.

Guardians Signature

Date Signed

Family Questionnaire This information is intended to help us understand you family, your youth, and his/her development.

Preschool & Kidcamp Family Questionnaire

This information is intended to help us understand your family, your youth, and his/her development.

Youths Name

Youths Nickname

Has your youth had previous youthcare/preschool?
Yes No

If yes, which school?
What are your views on education and what is your reason for choosing preschool for your youth?
How does your youth adapt to new situations?
What are your youth’s interests and/or what does your youth enjoy doing?
Are there any activities or foods your youth is unable to participate in due to medical, physical, social, or religious reasons? Please explain:
Who are the primary caregivers of the youth including parents (those who have significant contact with your youth and/or who may participate in your youth’s care)?

Name

Living with youth?
Yes No

Age

Family Member Role
Relationship with brothers, sisters, and other youth

Name

Living with youth?
Yes No

Age

Family Member Role
Relationship with others living in the home

Name

Living with youth?
Yes No

Age

Family Member Role
Does your youth have any problems with sleeping? How does your youth show that he/she is tired? Does your youth nap at home?
Is your youth afraid of anything (i.e. dogs, loud noises, bugs, etc.)?
How does your youth express anger or react to frustration? How does your youth express pleasure, excitement, or joy?
What do you expect of your youth?
What is your guidance strategy at home?
What is your youth’s primary language? How does your youth communicate his/her needs (please include primary language words for bathroom — urination and bowel movement, thirsty, hungry, tired, Mom, Dad, etc., if not English)?
Does your youth speak a second language?
Yes No

If yes, what is the second language?
Are there any customs, traditions, holidays, or special occasions that you celebrate with your youth and/or your family? Please explain

Would you be willing/able to come into class to share these traditions with all the kids?
Yes No
Is there any other information we should know to best work with your youth (therapy youth has, special needs, temperament, what you would like to see take place in class, etc.)?
Please attach a picture of your family for us to use in the classroom
Please attach a picture of your youth for us to use in the classroom

Medical Release Form

Only fill out this and the following medical pages if your youth has allergies, asthma, or medical needs.

Please fill out:

This Medical Release Form

Medical Administration in School or Youth Care (filled out by your youth's physician)
Colorado School Asthma Care Plan/Allergy and Anaphylaxis Action Plan and Medication Orders (filled out by your youth's physician)

My youth , DOB has various allergies and/or asthma. They consist of:

They do not require use of an EpiPen, inhaler or any other form of medication while at school. Therefore, I will not be providing the school wit any medications.

Please watch for the symptoms listed below. Please contact me at the number below if my youth has been exposed to any of the above allergens. I agree to keep my youth home if they have any symptoms of these allergies and/or asthma.

Name of people and numbers to call (in order, include self):

Emergency Contact Info

Emergency Contact Name

Emergency Contact Cell Phone Number

Emergency Contact Relationship

Emergency Contact Work Phone Number

Emergency Contact Address

Address Line

Address Line 2

City

State

Zip
Emergency Contact Info

Emergency Contact Name

Emergency Contact Cell Phone Number

Emergency Contact Relationship

Emergency Contact Work Phone Number

Emergency Contact Address

Address Line

Address Line 2

City

State

Zip
Emergency Contact Info

Emergency Contact Name

Emergency Contact Cell Phone Number

Emergency Contact Relationship

Emergency Contact Work Phone Number

Emergency Contact Address

Address Line

Address Line 2

City

State

Zip
Emergency Contact Info

Emergency Contact Name

Emergency Contact Cell Phone Number

Emergency Contact Relationship

Emergency Contact Work Phone Number

Emergency Contact Address

Address Line

Address Line 2

City

State

Zip

Signature of Parent or Legal Guardian

Date

Preschool and Kid Camp Parent Contract and Permissions Form

I will abide by the rules set by the City of Thornton Licensed Programs in order to ensure the safety and well being of all participants and their families. Initials
I understand the process followed should disciplinary measures be necessary Initials
I authorize my youth to participate in supervised walking field trips with the City of Thornton Licensed Programs Initials
I authorize my youth to view a video selected and /or developed by the staff. Parent will be notified before video is shown Initials
I have read and understand the policies and procedures outlined in the parent information packet Initials
I agree to apply sunscreen with a minimum SPF of 15 according to manufacturer instructions not more than 15 minutes prior to the arrival of my youth to the facility. I understand that youth may go outside each day and will apply sunscreen every day the youth is attending class. I understand that the center does not provide sunscreen nor have any on site for youth’s use

Signature of Parent or Legal Guardian

Date

Youth's Name

Preschool/Kid Camp Late Pick Up Fee And Payment Agreement

PRESCHOOL & KID CAMP I YOUTH WHO ARRIVE OR ARE PICKED UP LATE Youth who arrive late should enter the classroom quietly and join in the ongoing activities. Please be prompt when picking up your youth from his/her class. Staff members have 15 minutes to clean and prepare the classroom before the arrival of the next class. If the youth is not picked up 5 minutes after the class has ended, the preschool staff will start making necessary phone calls from your information form.

Late pick up fees will be charged to your household account if not paid immediately at the front desk.
You will be charged $1 per minute that you are late.
A receipt will be given to you for your payment.
A youth will never be left alone in the classroom.
Consistent and/or extended instances of late pick-ups may result in forfeiture of your child’s spot in the program without a refund
If the parents or emergency contacts can not be reached 30 minutes after class has elapsed, the Recreation or Community Center will then turn the youth over to the City of Thornton Police Department and Adams County Social Services. Every reasonable effort will be made to contact the parent/guardians or authorized contact person before this time.

MONTHLY PAYMENT AGREEMENT FOR PRIVATE PAY PRESCHOOL TUITION

Payment can be made in full or on a monthly basis for the entire school year, September – April.
The $45 registration fee is due by June 1 or, if registering during the school year, at the time of registration. If paying monthly, May’s payment is due August 1 or, if registering during the school year, at the time of registration. All remaining payments will be due on or before the third of each month. For example: October payment is due on or before October 3. You have the option to participate in the automatic credit card process or pay in person.
The May tuition deposit is used to hold a participant’s spot in a program. It is due by August 1, or if registering during the school year, is charged at the time of registration and is considered part of the cost of the program per participant, per program session (i.e. the entire school year). May’s tuition is due August 1. If your youth remains registered through the end of the school-year (May), your deposit will be applied to May’s tuition. If you cancel out of the program at any time after paying, your deposit becomes non-refundable.
A $15 LATE FEE WILL BE ASSESSED FOR ANY PAYMENT RECEIVED AFTER THE FIFTH OF THE MONTH. IF PAYMENTS ARE TWO WEEKS PAST DUE AND/OR HABITUALLY LATE, YOU WILL FORFEIT YOUR YOUTH’S SPACE FOR THE REMAINDER OF THE SCHOOL YEAR.
If you forfeit your youth’s space, you may then meet with the director to discuss the option of putting your youth’s name on a wait list or trying to get him/her into one of our other classes.

Signature of Parent or Legal Guardian

Date

Licensed Programs MEDIA WAIVER/PHOTOGRAPH PUBLISHING POLICY At times, different media groups (newspapers, television, public relations, etc.) will cover activities at the City of Thornton Preschool with articles, video or still photography that may be published. In addition, the Licensed Programs may want to include photographs in various artwork to be displayed in the preschool hallway.

If parents DO NOT want their youth to be photographed or videotaped for news media or preschool purposes, please complete an “opt-out media form” that may be obtained from the preschool director. Simply complete the form and return it to the preschool director so the preschool has a record of your request that your youth is NOT to be photographed or videotaped during class. This opt out does not apply to other public programs, events or facilities.

The City of Thornton preschool staff will make every reasonable effort to identify the primary subjects in photographs and to not publish preschool-related photos containing students on the opt-out list.

This form is effective for the current school year your youth is registered for.

Attachments

Please download the following forms which need to be filled out by the parent/guardian as well as the youth's physician and attach the completed forms below. These forms are required for camp participation.

If you have existing forms that are already filled out and valid for the upcoming sessions, you do not need to fill out new forms. You can simply attach the existing forms to this submission. Please make sure that the forms you are submitting are valid for the upcoming sessions. For example, if you are submitting an immunization record form, please make sure that the immunizations listed on the form are up to date and valid for the upcoming sessions.

If you do not have these forms filled out at time of submission, they can be filled out and emailed in later or a physical copy can be dropped off.

Colorado Immunization Requirements (Informational Only)
Colorado Allergy And Anaphylaxis Form
Colorado Asthma Care Plan
Colorado Immunization Record Form
General Health Appraisal Form
Medication Authorization Form

General Health Appraisal

Medication Authorization

Colorado Allergy And Anaphylaxis

Colorado Asthma Care Plan

Colorado Immunization

Preschool & Kid Camp Sign Ups

Preschool & Kidcamp Family Questionnaire

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