Creative learning for children ages 3-13
July 1 - 26, 2019

Online Medical and Pick-Up Authorization Form

Important: If you registered by mail, please fill out and submit this form in order to complete the registration process for your child(ren). If you registered online, click here.

NOTE:  Submit these completed forms back to us no later than June 20 and we will send you a pass that will enable you to bypass the registration desk and go directly to your child's classroom. Passes will be mailed mid-June.  This is highly recommended.

TWO SIGNATURES are required (emergency consent and pick-up authorization sections).  Note the "X" where signatures are required.  Forms not signed in both places will be returned.

Complete all sections of this form. If you have any medication, an epipen, inhaler or any other special item for your child, please give it to our nurse, who can be found in the Clinic. Our Nurse will have possession of these items at all times unless other arrangements have been made with you.

Child(ren)'s Last Name

Child's Name Birthdate
Child's Name Birthdate
Child's Name Birthdate
Child's Name Birthdate
Complete Address
Home Phone

Emergency Contact Information

cell phone work phone
other contact
Child(ren)'s Doctor Doctor's Phone
Insurance Company Insurance Policy Number

Allergies Allergy and Medication Authorization Forms can be found on our website.

Child Allergy
Child Allergy

Emergency Consent Form:  I, the undersigned parent or legal guardian of above named child(ren)  will not hold Kaleidoscope, its agents, servants or employees responsible for any accidents incurred during participation in the Kaleidoscope program.  If parents or doctor cannot be reached in case of emergency, consent is hereby given that the student receive medical treatment and/or surgical care as recommended by physician or hospital.

X
Parent Signature (required) Date

Your typed name is considered your signature

Pick-up Authorization

NOTE:  Parent signature required even if parent(s) is/are only person/people authorized to pick up child(ren).

The person (people) authorized to pick up my child(ren) is (are) (include child's parents):

Parents:                   

Other Authorized Person(s)

X
Parent Signature (required) Date

Your typed name is considered your signature.