Enrollment | KIP Learning, Inc.

Enrollment

To enroll at KIP Learning, Inc. please complete and press the SUBMIT button at the bottom this page. A signed form and a meeting with the staff of KIP Learning, Inc. is required to complete enrollment.

WHAT PROGRAM ARE YOU INTERESTED IN?

School Year

Summer Camp

Preschool

INFORMATION ABOUT CHILD

Child's Name

Start Date

Teacher's Name

School

Grade Previous School Year

T-Shirt Size

Sex

Male Female

Age (as of 5/27)

Date of Birth

Address

Parent Email

Home Phone

Child lives with

Mother Father Both Parents Other

MOTHER'S INFORMATION

Mother's Name

Mother's Address

Mother's Home Phone

Mother's Cell Phone

Mother's Pager

Mother's Employer

Mother's Work Phone

FATHER'S INFORMATION

Father's Name

Father's Address

Father's Home Phone

Father's Cell Phone

Father's Pager

Father's Employer

Father's Work Phone

EMERGENCY INFORMATION
In the event of an emergency, please contact the following individual(s):

Contact 1

Name

Phone Number

Relationship to Child

Contact 2

Name

Phone Number

Relationship to Child

Contact 3

Name

Phone Number

Relationship to Child

CHILD PICKUP PERMISSION
In addition to the person signing this application, authorization to pick up my child is given to the following person(s):

Pickup 1

Name

Identification

Relationship to Child

Pickup 2

Name

Identification

Relationship to Child

Pickup 3

Name

Identification

Relationship to Child

NAME OF CHILD'S PHYSICIAN OR CLINIC

Name

Company Name

Phone Number

SPECIAL NEEDS
My child has the following special needs and requires the following accomodations:

EMAIL BILLING OPTION
I would like to have invoices sent to my email account so I can pay them online with a credit card. I agree to the 3% processing fee added per transaction.

YES

Signature of parent or guardian will be required to complete this application. By signing this form, I acknowldege that I have read the KIP Learning Inc.'s policies and procedures and agree with them.

Parent/guardian signature___________________________ Date______

Media Release

I, the undersigned, do hereby grant permission to KIP Learning Center to use the image of my child, __________________, as marked by my selection(s) below. Such use includes the display, distribution, publication, transmission, or otherwise use of photographs, images, and/or video taken of my child for use in materials that include, but may not be limited to, printed materials such as brochures and newsletters, videos, and digital images such as those on the KIP Learning Center Web site.

Deny permission to use my child’s image at all.

Grant permission to use my child’s image in the following ways (mark all that apply):

Limited usage: I want my child’s image used within the KIP Learning Center setting only (not in the larger community).
Limited usage: I want my child’s image used for educational materials only (not marketing). This could be either within KIP Learning Center or in the larger community. One example of this could be videos in parent education classes.
Limited usage: I want my child’s image used on printed materials only (no digital or video use).
Unrestricted usage: I give unrestricted permission for my child’s image to be used in print, video, and digital media. I agree that these images may be used by KIP Learning Center for a variety of purposes and that these images may be used without further notifying me. I do understand that the child’s last name will not be used in conjunction with any video or digital images.

Parent/guardian signature___________________________ Date______

If you have questions, contact Sharon Woods at (770) 482-6112.