Galaxy Kids School-Age Childcare Summer Contract/Registration Form
2017 Summer Program. Please fill out a separate form for each child.
Child's First name
Your answer
Child's Last Name
Your answer
Child's Date of Birth
MM
/
DD
/
YYYY
Child's Gender
Child's Grade for 2017-18 School Year
Child's T-Shirt Size
Children's sizes. Once t-shirts are ordered, alternate sizes will not be available.
Names of Parents/Guardians
Your answer
Email Address of Parent/Guardian
Most emails will be sent to the email addresses listed on your Parent Portal.
Your answer
Name and phone number of person responsible for payment
Your answer
Care Selection
Schedule Selection
Please note you must schedule a minimum of 8 days per month if selecting the calendar option. If you select less than 8 days per month you will be billed the drop-in rate.
Who should we call if your child is ill or if there is an emergency?
Please list name and phone number.
Your answer
Please list the names of all people authorized to pick up your child.
Your answer
Please list any allergies or medical information Galaxy staff should be aware of.
This information will only be viewed by GKP staff. If no allergies or medical information, please enter "None". If your child requires medication during program hours, please contact Galaxy staff for a Medication Authorization Form.
Your answer
Please list special health or developmental needs Galaxy staff should be aware of.
This information will only be viewed by GKP staff. If no health or developmental needs, please enter "None".
Your answer
By checking the box below you are stating you have read and agree to abide by the Galaxy Kids Program Handbook/Policies.
The Galaxy Kids Program handbook is available on our website or on-site in our classroom.
Required
Galaxy Kids Program Contract Information
Please read each of the statements below carefully and check the box next to each one to acknowledge you understand each statement. If you have questions, please contact Galaxy staff before completing this form. All registrations are due by May 15. Registrations received after May 15 will be placed on a waiting list and you will be contacted with a start date when space is available.
Required
Required
My child attends Rockford Area Schools.
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