EES Student Information Enrollment Form

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Email *

Date of Enrollment *

YYYY

Full Name *

Student Address *

Date of Birth *

YYYY

Gender

Female

Male

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Age *

Grade *

Are immunizations up to date? (You are required to submit a copy to the center before your child can attend. ) *

Yes

Emergency Contact Name and Phone Number (Please list in order to be called 1, 2, 3 etc...) *

Current/Preferred Doctor Information (Must include Name, Address & Phone Number) Please include all three. *

Current/Preferred Dentist (Must include Name, Address & Phone Number) Please include all three. *

Preferred Hospital (Must include Name, Address & Phone Number) Please include all three. *

Emergency Medical Authorization: A parent/guardian must provide Barren Beyond the Bell consent for emergency medical treatment to be initiated for their child in the event of an emergency. A parent/guardian may also refuse to grant consent. If you would like to deny consent, please contact Sonya Davis (sonya.davis@barren.kyschools.us) *

Yes

In the event reasonable attempts to contact me or a second parent/guardian at the members listed in my emergency contact information have been unsuccessful, I hereby give my consent for: The administration of any treatment by a physician or dentist have listed on the next page, or in the event the designated preferred physician is not available, by another licensed physician or dentist. *

Yes

Please list any medical conditions that our facility needs to know about the student. *

Please list all individuals, relationship and phone numbers that are authorized to pickup the student. *

I give permission for my child's image, voice, or written comments to be included in evaluations, pictures, newsletters and marketing pieces associated with the program. Barren Beyond the Bell may use these indefinitely, without limitation of obligation for the purpose or promoting or interpreting Barren Beyond the Bell programs. *

Yes

We may show PG rated movies in our program. Do you consent for your child to watch? *

Option 1

Yes

I give my permission for my child to use all of the equipment and participate in all activities of the childcare programs. *

Yes

I understand that Barren Beyond the Bell assumes no responsibility for injuries or illnesses which may occur as a result of my child's physical condition or resulting from his/her participation in any athletic event, sports programs, and the use of any equipment, exercise or other activities. *

Yes

I acknowledge on behalf of myself and my dependents that I assume the risk for any injuries or illnesses which may result from activities. I hereby release and discharge the Barren Beyond the Bell, it's agents, servants, and employees from any and all claims for injury, illness, loss or damage, which my child may suffer as a result of his/her participation in the childcare programs. *

Yes

I understand that Barren Beyond the Bell is not responsible for personal property lost or stolen while participating in the program. My child is responsible for all of his/her belongings. I understand that due to COVID there will be NO lost and found. *

Yes

I understand that the Barren Beyond the Bell is not responsible for anything that occurs as a result of false information given by a parent or guardian. *

Yes

I have read and understood the contents of the 2020-2021 Parent Notebook and agree to all the terms that are covered in the manual. I understand that my signature indicates that I have been previously made aware of all policies, procedures, and guidelines referenced in the notebook concerning this program. I have read and fully understand these policies and authorization statements. I do hereby give such authorization as indicated or document understanding of specific policies. *

Yes

I have not received a copy

By signing electronically below, you agree to acknowledge and adhere to all of the policies and procedures associated with these programs. These policies and procedures are outlined in detail in the 2020/2021 Family Handbook. *

Yes

I understand that there is a late fee of $1.00 per minute/ per child for any child left after the end time of the program. This payment will be made upon arrival, in cash and given to the staff person who remains after scheduled work hours to be with my child. *

Yes

I understand that I can not pay in advance due to unforeseen circumstances with our current COVID-19 situation and the unpredictability of the day to day operations in our facility. At this time we will not be making reimbursements. *

Yes

I understand that the Barren Beyond the Bell program will follow the local school schedule. If the children are scheduled to be off from school for the day our child care programs will NOT be available. *

Yes

I understand that under no circumstances will be child bring their own toys or other personal items, which include but are not limited to: personal electronic devices, cell phones, card games, etc. If my child does so, the staff will hold the item and return it to the parent/guardian at the end of the day. *

Yes

I understand that my child(ren) must be signed in and out of the program daily. This is a program requirement and must be done every day. If someone else picks up my child they will need to complete the sign in/out sheet and also provide staff with identification. *

Yes

I understand that if my child will be absent from the program I need to call or email the Barren Beyond the Bell staff prior to the start of the program. *

Yes

Are you interested in the Child Care Assistance Program? If you meet any of the following conditions you may be eligible for the CCAP program. - Work an average of 20 hours per week for a single parent and 40 hours combined for a couple. - A teen parent attending high school or pursuing a GED. - Currently participating in the SNAP Employment & Training Program. - Adult who is a full time student enrolled in a certified trade school or an accredited college or university. - Participate in Kentucky Works activities. - Need Child Care as a support for child protective/preventative services. Please go to the following website to apply: http://benefind.ky.gov *

Yes

Child Care Face Mask(DCC-410)-If you have a student that is in Kindergarten or below and would like for them to wear a face mask please indicate yes or no. We will have you sign a form. *

Yes

By clicking on the "I accept" button. You are agreeing to your electronic signature. Please Check the appropriate box. *

I accept

I decline

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A copy of your responses will be emailed to the address you provided.

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