Galaxy Kids School-Age Childcare School Year Contract/Registration Form
2017-18 School Year 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
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.
Care Selection
Check all that apply. Please note preschool tuition is separate from GKP tuition.
Required
Names of Parents/Guardians
Your answer
Email Address of Parents/Guardians
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
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.
Authorized people will be required to show a photo ID when picking 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 special 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 August 15. Registrations received after August 15 will be placed on a waiting list and you will be contacted with a start date when space is available.
Required
By checking the box below you authorize that you are the legal parent/guardian of the student named on this form and that you recognize this is your legal and binding electronic signature, and that any fraud or inaccuracy will void this student's eligibility.
Required
I have an Infinite Campus Parent Portal.
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