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KinderBoost™ Application
Welcome to KinderBoost™!

We are pleased to offer a two-week KinderBoost™ program for your child. This two-week program will be run by teachers who will work together to provide a variety of activities to prepare your child for the start of Kindergarten.  

On the first day of the program, we invite parents and guardians to join us for a Kindergarten Readiness Workshop. During this time, you will receive helpful hints and suggestions to help you with preparing your child for Kindergarten. You will also have the opportunity to meet other school staff, as well as meet other Kindergarten families. In addition, we will be giving away Family Literacy Kits full of fun activities for you to use with your child at home.

First Day of Program – Kindergarten Readiness Workshop Materials given to the parent/guardian:
• Summer Activity Booklet
• Is Your Child Prepared for Kindergarten Checklist
• Pre-Reading Skills for Reading Success Checklist
• Phonemic Awareness and Math Magnetic Activity Tins & Parent Handout

The last day of the program, we ask that you join your child for a special family literacy event and graduation ceremony. This will include literacy activities for you to participate in with your child, as well as additional games and activities to take home. Immediately after the Family Literacy Event will be a ceremony where your child will receive a graduation certificate along with a brand-new backpack full of school supplies! We certainly hope that you can join us for these special activities!

Last Day of Program - Family Literacy Event & Graduation Celebration Materials given to the parent/guardian:
• Learning Games and Activities
• KinderBoost™ Graduation Certificate
• Backpack with school supplies and learning materials

Materials given directly to children (for use at home together with their family):

Some learning materials will be given directly to the children during KinderBoost™, however, we suggest you take some time to look over the materials and use them together as a family!

First Friday of Program-In-School Field Trip:
Save the Children Summer Reading Book Bag that includes:
• Pete the Cat: Too Cool for School by James Dean
• School (First Time) by Jess Stockham
• Curious George’s First Day of School
• Biscuit Goes to School
• Parent Tips for Kindergarten/Tips for Reading With Your Child


Here is an example of what the daily schedule for your child may look like: (schedules and times will vary by site)

8:00-8:30       Arrival/Breakfast
8:30-8:45       Opening Song or Activity
8:45-9:45       Calendar and Morning Circle Time
9:45-11:00       Learning Centers
11:00-11:30        Choosy Kids Physical Activity
11:30-12:00        LUNCH
12:00-12:15        Recess
12:15-1:00       Story time and extended activity
1:00-1:45            Learning Centers
1:45-2:00            Goodbye songs and dismissal

To apply for the KinderBoost two-week program, please complete the attached form. 20 children will be selected to participate at each school based on level of need and availability.
 
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Email *
Child's First & Last Name *
Child's Date of Birth *
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YYYY
Child's Age *
Child's Gender *
Child's Race *
Child's Ethnic Origin *
Child's Address *
City *
Zip *
County where child will attend Kindergarten *
School where child will attend KinderBoost *
Transportation Needs (if applicable in your district) *
Mother/Guardian Name *
Mother/Guardian Home Phone #
Mother/Guardian Work Phone #
Mother/Guardian Cell Phone # *
Mother/Guardian Email Address *
Father/Guardian Name
Father/Guardian Home Phone #
Father/Guardian Work Phone #
Father/Guardian Cell Phone #
Father/Guardian Email Address
EMERGENCY CONTACTS
In the event that parents/guardians cannot be reached in an emergency, Save the Children program staff will call a person listed below. People listed should be individuals who can: 1) give permission to administer health care 2) pick up your child if your child is ill or 3) give advice about caring for your child. **If you have more than two emergency contacts or individuals that will be picking up your child, please give that information to the site coordinator at your school.

Emergency Contact # 1 Name *
Emergency Contact # 1 Address *
Emergency Contact # 1 Home Phone *
Emergency Contact # 1 Work Phone *
Emergency Contact # 1 Cell Phone *
Emergency Contact # 1 Relationship to Child *
Emergency Contact # 2 Name
Emergency Contact # 2 Address
Emergency Contact # 2 Home Phone
Emergency Contact # 2 Work Phone
Emergency Contact # 2 Cell Phone
Emergency Contact # 2 Relationship to Child
HEALTH INFORMATION
Physician *
Physician Phone # *
Medication(s) being taken by child *
Physical conditions (allergies, diabetes, asthma, etc.) *
If my child’s emergency contacts listed above, or the physician listed above, cannot be reached in an emergency, I authorize a Save the Children program staff member or legal representatives to obtain emergency medical care for my child while under the program’s care including transporting or sending my child to an available hospital or physician.
Parent/Guardian Signature *
ADDITIONAL INFORMATION FOR GRANT PURPOSES
The following information must be collected for ONLY ONE parent or guardian of the above child.  This information is a requirement of the grant that funds the KinderBoost program.  This information will be confidential and not shared with anyone.
Mother's Age *
Mother's Race *
Mother's Ethnic Origin *
Education of Mother/Guardian *
Employment of Mother/Guardian *
Employment of Mother/Guardian *
Employment Duration of Mother/Guardian *
Occupation of Mother/Guardian *
Employment Wages of Mother/Guardian *
Father's Age
Clear selection
Father's Race
Clear selection
Father's Ethnic Origin
Clear selection
Education of Father/Guardian
Clear selection
Employment of Father/Guardian
Clear selection
Employment of Father/Guardian
Clear selection
Employment Duration of Father/Guardian
Clear selection
Occupation of Father/Guardian
Clear selection
Employment Wages of Father/Guardian
Clear selection
ADDITIONAL KINDERBOOST INFORMATION
I will be attending the Kindergarten Readiness Parent Workshop on the first day of camp. Times will vary by site, but it normally lasts 2 hours and you will receive lots of free resources. *
I will be attending the final day of the program's Family Literacy Event Graduation Celebration.  Times will vary by site, but it normally lasts 2-3 hours. *
May we contact you after the KinderBoost™ program has concluded to ask for your feedback on how the program could be improved upon in the future? *
What is the primary language spoken in your home? *
These are some things my child enjoys doing:   *
What is your child most excited about with starting kindergarten? *
Is there anything your child has expressed he/she is worried about? *
Did your child attend preschool? *
Below are some skills that can help prepare your child for Kindergarten. Where do you think your child is at with learning these skills?
My Child Knows: Their first & last name *
My Child Knows: How to hold a pencil, crayon and marker *
My Child Knows: How to use scissors *
My Child Knows: How to sit still for 10-20 minutes at a time *
My Child Knows: How to take care of their own bathroom needs *
My Child Knows: How to work together in groups and get along with others *
My Child Knows: How to ask for help and express their needs *
My Child Knows: How to follow multi-step directions *
Original Materials, Interviews, Film, Photos, Tape and Video Consent and Release
In furtherance of Save the Children’s charitable mission, and without expectation of compensation or other remuneration, now or in the future, I hereby give consent to Save the Children and its affiliates and agents for the following:(a)  to interview, film, photograph, tape or otherwise make a video reproduction of me and/or my child;(b) to use, copy and publish original materials created by child (such as essays, poems, photos and artwork);(c)  to use my name and/or my child’s name; and,(d) to use my child’s original materials, my or my minor child’s image (whether photographic, video and/or electronic), interview statements (and excerpts of statements) from me or my child, in whole or in part, in Save the Children’s publications, in newspapers, magazines and other print media, on television, radio and electronic media (including the ”Internet”) in theatrical media and/or in mailings for educational and awareness campaigns by Save the Children, in connection with the promotion of Save the Children products, and/or to help raise funds for Save the Children. This consent is given without expiration, and futures uses do not require additional permission from me. The below signed individual, parent or legal guardian hereby consents to and gives permission to the above.
Signature of Responsible Individual / Parent / Legal Guardian:     (If you do not grant permission, please write, "Do not give permission" below)                                       *
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