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Forms and information

Enrollment Application

Child's Birthday or Anticipated Due Date
Month
Day
Year
Gender
Male
Female
Custodial Parent?
Yes
No

If you prefer, you are welcome to call our office directly (225-928-0801) or email KidsCount@KidsCountBR.com and McKenna@KidsCountBR.com to schedule a tour.


We are so excited to show you what Kids Count has to offer for you and your family. We cannot wait to welcome you!

Payment Information
and Authorization

I am submitting payment information for

Automated Payment Processing powered by Procare Solutions/Tuition Express. The system allows secure, on-time tuition and fee payments to be made from either your bank account or credit card. *Note, there is a 3% processing fee added to all credit card transactions.


Electronic Funds Transfer Authorization

Selection:
Section A - Credit Card *subject to 3% processing fee
Section B - Bank Account

Complete only the section based on your selected payment method:


Credit Card

Bank Account

Single choice
Checking
Savings

Emergency Contacts
and Authorized Pick-Ups

Please Select One of the Following:
This is my first time to submit this form for my child.
This form is being submitted to supplement a previously submitted form on file.
This form is being submitted to REPLACE an existing form for this child.

Persons Authorized to Pick Up Child:

Emergency Contact?
Yes
No
Emergency Contact?
Yes
No
Emergency Contact?
Yes
No
Emergency Contact?
Yes
No

Does your child have any food allergies?

Single choice
Yes
No

Does your child have any other allergies?

Single choice
Yes
No

Does your child have any dietary restrictions?

Single choice
Yes
No

Does your child have any special needs or health concerns?

Single choice
Yes
No

Permission for Healthcare

PERMISSION FOR HEALTHCARE

Child's Primary Care Physician

Authorized Adults:

In the event of an emergency, please indicate your name and phone number where you and another authorized person can be reached:

First Aid:

In the event of an emergency, I authorize the staff to provide any first aid care deemed necessary for my child.

Emergency Care:

In the event of an emergency in which I cannot be reached, the physician listed above, and the local hospital, are hereby authorized to provide any emergency care deemed necessary for my child.

Health Record Transfer:

In the event of an emergency, I hereby authorize the transfer of my child's health record to the local hospital.

Authorization for topical products and water activities authorization

Authorization for the

Application of Topical Products

I give my permission to Kids Count staff to apply the following topical products (parent-provided) to my child:

Sunscreen

Insect Repellant

Diaper Rash Ointment

Other:

This one-time authorization will remain in effect until a new authorization is signed.

Water Activities Authorization

has permission to participate in the following type(s) of water activity:

Outdoor water sprinklers on designated "Water Days" and/or water tables for science/sensory activities

Location of activity: Kids Count Playground, outdoor areas, or classrooms

*Children under the age of two (2) years old will not participate in water activities*

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