1. education
2. school

HOW TO REGISTER CHECKLIST
1) Verify the date and time of your school’s registration event. Please fill out one complete
registration packet for each child.
2) If you are a current family with the program your account balances MUST BE PAID IN FULL no
later than June 3, 2013 or your registration for the 2013/2014 school year will be revoked.
3) If you are a current family and you do not have your Pre-Registration packet to turn in please
fill out another registration packet.
4) All New Families must complete the 2013-2014 Registration Packet. This packet MUST be
completed in its entirety. An incomplete packet WILL NOT be accepted. Please use this
checklist to help you gather the necessary information.
 PAYMENT AGREEMENT:

_____
Name of responsible party and Email address
_____
Child’s name, age, date of birth, and KC Site
_____
How you would like to receive your statements
_____
If you would like to receive Text Messaging Alerts
_____
Registration Fee (select one)
_____
Your child’s Schedule
_____
Form of payment for billing
_____
Tuition Express Form
_____
Payment Terms read and initialed
_____
Signed & dated by responsible party
_____
Signed & dated by KC staff person
INFORMATION CARD:
The Information Card must be completely filled out. If you have no information for any
section or field please indicate N/A (Not Applicable) in the blank space provided.
_____
Your child’s full name, age, gender, grade, student ID, current address, and enrollment date
_____
Complete names, addresses, and phone numbers for parents/guardians
_____
Complete name and phone number for 2 emergency pick-up contacts
_____
Your child’s medical history, allergies, chronic medical problems, and special needs information
_____
Complete names, addresses, and phone numbers for your child’s doctor and dentist
_____
Hospital selection in case of emergency
_____
A copy of your child’s current immunizations (MUST be included)
_____
A copy of your child’s current health appraisal form (MUST be included)
_____
Authorization form signed and dated that may include the following: Sign In/Out Authorization,
Activity Authorization, and Sunscreen Authorization
5) Turn in your registration packet for review by a KC staff member.
6) Pay the registration fee with check, money order, MasterCard or VISA (No cash please)
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Payment/Registration Fall 2013/2014
Parent or Guardian Name
Email #1
Email #2
Child Name
Age
DOB
KC Site:
Email Statements?
 Yes
 No
(If YES, you will no longer receive statements via US Mail.)
Text Message Alerts:
 Yes
 No
(If YES, please indicate provider and cell number below.)
Cell Number #1:____________________________ Carrier_________________________________
Cell Number #2:____________________________ Carrier_________________________________
Standard data rates may apply
PLEASE CHECK ONE:
Single Child
Fall Registration Fee
NEW! Fall/Summer Registration Fee
(includes school year 2013-2014 and summer 2014)
Multiple Children
School Year Camps Only
 $60.00
 $85.00
 $75.00
 $120.00
 $15.00 Fall Camps
A savings of $10!
A savings of $15!
MONTHLY
AMOUNT
Please CHECK the scheduled days of the week per program.
EARLY RISER
(6:30am – classroom start time)
Kadoodles PM
(Noon – School release) Not at all sites
AFTER SCHOOL
(School release – 6:00pm)
Friday 1 – 3 pm (certain sites)
 T
 W
 TH
 F
 M
 T
 W
 TH
 F
 M
 T
 W
 TH
 F
ONLY IF REGISTERED FOR A 3 DAY MINIMUM PROGRAM
Friday 1 – 6 pm (certain sites)
Automatic Payment Option:
 M
$24.00
$96.00
Tuition Express ID#
Available Financial Assistance (Only one discount will apply per family. Multiple discounts will not be allowed)
I understand, if I apply for financial assistance it will not be applied to my account until the Kaleidoscope Corner Financial Office
has received my income verification and determined my eligibility.
Required Paperwork for Financial Assistance:
 Application
 Most recently filed income tax return
 Two most recent paycheck stubs
Human Services:
CCAP Case Number: ___________________________________________________________________
 If you are a CCAP recipient, you must present written authorization from your county caseworker for the current
school year and site location at the time of registration. If you do not have written authorization you will be
responsible for all tuition charges and deposits at the time of registration. _________________________
Parent Initials required
Check #:_________________________________________
For KC Staff Use Only: Method of Payment
Credit Card (Transaction Code)#: _________________________________________
M.O.#:_______________________________________________________________
Cash Receipt#: __________________________________________
SCHEDULE OF PAYMENTS
Payment/Billing cycle
run date
1 of 9
August 15th
2 of 9
September 15th
3 of 9
October 15th
4 of 9
November 15th
5 of 9
December 15th
6 of 9
January 15th
7 of 9
February 15th
8 of 9
March 15th
9 of 9
April 15th
Tuition Due Date &
Tuition Express Run Date
Late Fee Assessed
Non-Payment
Withdrawal Date
Coverage Period
9/3/13
9/10/13
9/19/13
8/26/13 – 9/30/13
10/1/13
10/8/13
10/17/13
10/1/13 – 10/13/13
11/1/13
11/8/13
11/20/13
11/1/13 – 11/29/13
12/2/13
12/9/13
12/18/13
12/1/13 – 12/31/13
1/2/14
1/9/14
1/22/14
1/1/14 – 1/31/14
2/3/14
2/10/14
2/20/14
2/1/14 – 2/29/14
3/3/14
3/10/14
3/19/14
3/1/14 – 3/31/14
4/3/14
4/10/14
4/21/14
4/1/14 – 4/30/14
5/1/14
5/8/14
5/19/14
5/1/14 – 6/6/14
TERMS OF PAYMENT AGREEMENT (Please read and initial all applicable statements)
th
INVOICES - I understand that Kaleidoscope Corner will generate and send monthly invoices on the 15 of each month. ________
PAYMENT RESPONSIBILITY - I understand that I, the signer of this document, am fully responsible for payment. Kaleidoscope Corner will
not process split billing between two parents or guardians on one account. ________
st
I understand that it is my responsibility to pay monthly tuition by the 1 business day of each month. ____________
LATE FEE - I understand that if my payment is not received within 5 business days of the tuition due date, a $25 non-reversible late fee will
be assessed to my account. ________
SERVICE FEES - I understand that a $30 service fee will be assessed for every returned check and a $15 service fee for every credit card
decline. ________
TERMINATION DUE TO UNPAID BALANCE - I understand that if payment is not received within 13 business days of the tuition due date,
my child (children’s) enrollment will be terminated. ________
I understand that if my child is withdrawn due to an unpaid balance, I must contact the Kaleidoscope Corner registration office to obtain
reinstatement eligibility information before returning to the program. ________
SPLIT PROGRAM BILLING - I understand that if I elect to create two accounts to split program billing that each parent will be fiscally
responsible and must register and apply for financial assistance if needed. If non-payment occurs on one account the child will be
withdrawn for the corresponding program resulting in non-payment. ________
WITHDRAWAL - I understand in order to withdraw from the program I must complete the proper forms one week in advance. Failure to
do so will result in my account being charged full price for that current billing month. I understand that my withdrawal is official when I
receive confirmation from the KC Registration Office. ________
CREDITS OR REFUNDS
I understand that credits or refunds are NOT issued for routine absence or illness. Credits will be considered for extended absence or
illness with signed documentation from a medical professional. ________
I understand that credits or refunds are NOT issued for days Kaleidoscope Corner is closed due to district or school closures for
circumstances such as inclement weather. ________
Human Service Recipients:
I understand that if I am receiving Human Service assistance that it is my responsibility to provide Kaleidoscope Corner with all eligibility
certificates. ________
I understand that I am responsible for paying parental fees, drop-ins, late pick up fees and the costs of any other unauthorized care
assessed to my account. ________
Parent/Guardian Signature
Date
Staff Signature
Date
KALEIDOSCOPE CORNER Information Card
CHILD INFORMATION
Start Date:
First Name
Date of Birth
Gender: Male
Female
M.I.
Last Name
Age
Grade
Ethnic Group you consider the child to be a member of:
Student ID #
(Ethnicity is needed for Federal Food Program)
School Child Attends
PARENT/GUARDIAN INFORMATION
Child lives with: (Circle one or more)
Mother
Father
MOTHER/GUARDIAN First Name
Last Name
Address
City
Home Phone
Cell/Pager
Other (Please Specify)
State
Zip
State
Zip
Employed By
Address
City
Office Phone
Email
Preferred Contact Number during Kaleidoscope Hours:
Order of Emergency Contact:
FATHER/GUARDIAN First Name
Last Name
Address
City
Home Phone
Cell/Pager
First
Second
State
Zip
State
Zip
Employed By
Address
City
Office Phone
Email
Preferred Contact Number during Kaleidoscope Hours:
Order of Emergency Contact:
First
Second
EMERGENCY CONTACT INFORMATION (ALL EMERGENCY CONTACTS MUST BE 18 AND OLDER)
EMERGENCY CONTACT
Relationship to Child:
First Name
Home Phone
(CHECK ONLY ONE)

1

2

3

4

1

2

3

4
Last Name
Office Phone
EMERGENCY CONTACT
Relationship to Child:
First Name
Home Phone
Order of Emergency Contact:
Cell/Pager
Order of Emergency Contact:
(CHECK ONLY ONE)
Last Name
Office Phone
Cell/Pager
THE ABOVE PERSONS ARE AUTHORIZED TO PICK UP MY CHILD AND WHOM KALEIDOSCOPE CORNER MAY CONTACT IN THE
EVENT OF AN EMERGENCY IF PARENT(S) OR GUARDIAN(S) CANNOT BE REACHED. ALL EMERGENCY CONTACTS MUST BE 18 AND
OLDER
Parent/Guardian Signature: ______________________________________________________________ Date: ____________________________
SPECIAL NEEDS INFORMATION
Has your child been
If yes, what special accommodations or modifications are needed?
Yes
No
identified as disabled?
Does your child have an
If yes, what special accommodations or modifications are needed?
Yes
No
IEP or a 504 Plan in place?
 Speech/Language
 Vision
Check any of the following  Learning Disabilities
that apply to your child.
 Behavioral Disorders
 Physical Therapy
 Hearing
If any of the above questions have been answered YES a meeting with the Program Specialist and/or the Camp Supervisor is
required before my child may begin the program.
Parent/Guardian
Initials
ALLERGY/HEALTH INFORMATION
Child’s Name______________________________________________
Yes
No
Allergies
Does your child take medications for this?
Yes
No
Yes
No
Asthma
Does your child take medications for this?
Yes
No
Yes
No
Medical Problems (That Require Special Accommodations)
Yes
No
Dietary Needs (That Require Special Accommodations)
Yes
No
Yes
No
Other (That Require Special Accommodations)
Emergency Medications Required
Please list all EMERGENCY medications:
Yes
No
Parent/Guardian
Initials
Will your child require Daily Medications DURING PROGRAM/CAMP HOURS?
Please list all DAILY MEDICATIONS to be administered to your child during program hours:
Parent/Guardian
Initials
Please list all DAILY MEDICATIONS to be administered to your child during Dismissal Days and Break Camp hours:
Parent/Guardian
Initials
Does your child take medications on a daily basis?
Yes
No
We must record all daily medications your child takes, even if they will not be administered during program hours.
In an emergency, this information must be provided to paramedics.
Parent/Guardian
Please list all Daily Medications your child takes, at any time of day:
Initials
MEDICAL/HOSPITAL INFORMATION
**Doctor’s Name
Address
**Dentist’s Name
Address
**Preferred Hospital: (Please mark one)
Phone
State
Phone
State
City
City
Zip
Zip
Denver Health Medical Center
777 Bannock St., Denver, CO 80204
303-436-6000
Presbyterian/St. Luke’s Medical Center (PSL)
1719 E. 19th Ave., Denver, CO 80218
303-839-6000
th
The Children’s Hospital
13123 E. 16 Ave., Aurora, CO 80045
720-777-1234
Rose Medical Center
4567 E. 9th Ave., Denver, CO 80220
303-320-2121
Porter Adventist Hospital
2525 S. Downing St., Denver, CO 80210
303-778-1955
St. Joseph’s Hospital
1835 Franklin St., Denver, CO 80218
303-866-8600
th
Lutheran Medical Center
8300 W. 38 Ave., Wheat Ridge, CO 80033
303-425-4500
Swedish Medical Center
501 E. Hampden Ave., Englewood, CO 80110
303-788-5000
University of Colorado Hospital, Anschutz Campus
th
12605 E. 16 Ave., Aurora, CO 80045
303-372-0000
Name, Address and Phone # of Preferred Hospital (if not listed):
**Required Information – complete contact information on doctor, dentist and preferred hospital.
I do hereby authorize the above named physician to render such treatment as may be deemed necessary in an emergency for the health of the child. In the
event that a parent/guardian, or alternate person named on this form cannot be reached, or if the name of a doctor, dentist or hospital has not been provided,
the staff is hereby authorized to call 911 for medical assistance. The staff is also authorized to take whatever action is deemed necessary in their judgment for
the health of the aforementioned child.
Parent/Guardian Signature: __________________________________________________________________ Date: ________________________
SIGN IN/OUT AUTHORIZATION*
Child’s Name______________________________________________
I understand that Kaleidoscope Corner is not responsible for children that walk or bus from the program site once they are
signed out.
I understand that Kaleidoscope Corner requires parents to sign their children IN to Early Risers.
I give permission for my child to sign him/herself OUT of After School
Release Time ___________
My child may not sign him/herself out, and may not leave by her/himself.
Parent/Guardian
Initials
Parent/Guardian
Initials
Parent/Guardian
Initials
*Sign-out authorization is not available at the following locations: Brown, CEE, Denison, Dora Moore, Gilpin, Lincoln, Palmer, Park Hill, Roberts,
Sandoval, Swigert McAuliffe, Valdez, and Westerly Creek.
ACTIVITY AUTHORIZATION
I give permission for my child to appear in any media coverage approved by Kaleidoscope
Corner.
I give permission for my child to view:
Yes
No
G Movies
PG Movies
No Movies
(please circle any that apply)
Are there any activities your child
(If yes, please specify)
Yes
No cannot participate in due to physical,
social or religious reasons?
Personal Release Statement: I understand that there is risk of injury in any recreational or sport activity and I
voluntarily assume such risk. I take full responsibility for the actions and physical condition of my child. I agree to
indemnify and hold harmless the Department of Community Education and Denver Public Schools from liability, loss,
cost or expense (including attorney’s fees, medical, dental and ambulance costs) that my child may incur while
participating in Kaleidoscope Corner activities.
Yes
No
Parent/Guardian
Initials
Parent/Guardian
Initials
Parent/Guardian
Initials
Parent/Guardian
Initials
SUNSCREEN AUTHORIZATION
Kaleidoscope Corner will be providing Rocky Mountain Sunscreen SPF 30 (Find ingredients on our website) to students for use before
any outdoor play or activities.
Children 4 years of age and older must apply sunscreen to themselves under the direct supervision of a staff member. Kaleidoscope
Corner staff will not apply sunscreen to your child(ren).
Kaleidoscope Corner staff will be responsible for reminding your child to apply sunscreen prior to outdoor activities.
Kaleidoscope Corner staff will be responsible for applying sunscreen to children that are 3 years old.
If you do not want your child to use Rocky Mountain Sunscreen, please provide an individual bottle of sunscreen with your
child’s full name to Kaleidoscope Corner.
PLEASE CHECK ALL THAT APPLY:
YES, I authorize my child to apply Rocky Mountain Sunscreen SPF 30 while at Kaleidoscope Corner.
YES, I authorize Kaleidoscope Corner staff to apply Rocky Mountain Sunscreen SPF 30 to my 3-year-old child
while at Kaleidoscope Corner.
YES, I authorize my child to apply sunscreen which I will provide while at Kaleidoscope Corner. I understand that
the sunscreen I provide must be labeled with my child’s name.
YES, I authorize Kaleidoscope Corner staff to apply sunscreen to my 3-year-old child while at Kaleidoscope
Corner. I understand that the sunscreen I provide must be labeled with my child’s name.
NO, I do not authorize sunscreen to be applied to my child while at Kaleidoscope Corner and will apply sunscreen
to my child daily.
Parent/Guardian Signature: __________________________________________________________________ Date: ________________________
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GENERAL HEALTH APPRAISAL FORM
PARENT please complete AND SIGN
Child’s Name: _________________________________________________________________ Birthdate: _____________________
Allergies: ____ None or Describe: _______________________________________________________________________________________________________________
Type of Reaction: _______________________________________________________________________________________________________
Diet:
____ Breast Fed
____ Formula: _______________________
_____ Age Appropriate
_____ Special Diet: ________________________________________________________________________________________________
Sleep: Your health care provider recommends that all infants less than 1 year of age be placed on their back for sleep.
_____ Preventive creams/ointments/sunscreen may be applied as requested in writing by parent unless skin is broken or bleeding.
I, ________________________________________ give consent for my child’s care health provider, school child care or camp personnel to
discuss my child’s health concerns. My child’s health provider may fax this form (& applicable attachments) to my child’s school,
child care or camp personnel. FAX #: _____________________________ DATE: _____________________________
Parent/Guardian Signature_______________________________________________________________________
HEALTH CARE PROVIDER: Please Complete After Parent Section Completed
Date of Last Health Appraisal: _____________________________ Weight @ Exam: _______________________________________
Physical Exam: _____ Normal _____ Abnormal (Specify any physical abnormalities):_____________________________________________________
Allergies: ____ None or Describe: _______________________________________________________________________________________________________________
Type of Reaction: _______________________________________________________________________________________________________
Significant Health Concerns: _____ Severe Allergies _____ Reactive Airway Disease _____ Asthma _____ Seizures _____ Diabetes
_____ Hospitalizations
_____ Developmental Delays
_____ Behavior Concerns _____ Vision
_____ Hearing
_____ Dental
_____ Nutrition
_____ Other: _______________________________________________________________________________________________________________________________________
Explain above concern (if necessary, include instructions to care providers):
______________________________________________________________________________________________________________________________________
Current Medications/Special Diet: _____ None or Describe: _______________________________________________________________________________
Separate medication authorization form is required for medications given in school, child care or camp
For Fever Reducer or Pain Reliever (for 3 consecutive days without additional medical authorization) PLEASE CHOOSE ONE PRODUCT
_____ Acetaminophen (Tylenol) may be given for pain or fever over 102 degrees every 4 hours as needed
Dose ____________________ or see the attached age-appropriate dosage schedule from our office
OR
_____ Ibuprofen (Motrin, Advil) may be given for pain or for fever over 102 degrees every 6 hours as needed
Dose ____________________ or see the attached age-appropriate dosage schedule from our office
Immunizations: _____ Up-to-Date
______ See attached immunization record
_____ Administered today: ___________________________
Provider Signature
Next Well Visit: _____ Per AAP guidelines* or _____ Age:__________
This child is healthy and may participate in all routine activities in school sports, child care
or camp program. Any concerns or exceptions are identified on this form.
____________________________________________________________________
Office Stamp
Or write Name, Address, Phone, #
Date: _______________
Signature of Health Care Provider (certifying form was reviewed)
The Colorado Chapter of the American Academy of Pediatrics (AAP) and Healthy Child Care Colorado have approved this form. 04/07
*The AAP recommends that children from 0-12 years have health appraisal visits at: 2, 4, 6, 9, 12, 15, 18 and 24 months,
and age 3, 4, 5, 6, 8, 10 and 12 years.
Copyright 2007 Colorado Chapter of the American Academy of Pediatrics