SHED Registration Form

"*" indicates required fields

Child's Name*
MM slash DD slash YYYY
Address*

Program Information

All programs require a 30-day notice to make any schedule adjustments.
MM slash DD slash YYYY
Please Select the SHED Program You're Registering For:*
Parent/Guardian Name*
(if not applicable write N/A)
Parent/Guardian Name
Kids Club ONLY:
Is there documentation of a physical exam, immunization record, and lead screening on file at your child’s school?
dietary restrictions, allergies, chronic health conditions, ect.

Child Identifying Information

Required by the Early Education and Care (EEC) Regulations:

SHED Before & After School Programs

Please select the days attending
Before School (7:30 am-9am):
After School (3:30-6pm):
Full Time Afternoons:

Forest Kindergarten (8:30 AM - 3:30 PM) Mon - Fri

Please select the extended time and day if applicable.
Forest Kindergarten
Extended Day until 6 PM

Springboard to Kindergarten – (8:30 AM - 3:30 PM) Mon - Fri

Please select the extended time and day if applicable.
Springboard t0 Kindergarten
Extended Day until 6 PM

Monarch Preschool

Please select the days and time your child will be attending:
Full Time (8:30 AM - 3:30 PM)
Full Time 2 - 5 days 8:30 AM - 3:30 PM
Part Time (8:30 AM - 12 PM) 2-5 days
Extended Day until 6 PM
Need 5 children per day registered for this extension to open

Caterpillars Toddler Program

Please select days attending:
Full Time (8:30 AM - 3:30 PM)
Full Time 2 - 5 days 8:30 AM - 3:30 PM
Part Time (8:30 AM - 12 PM) 2-5 days
Extended Day until 6 PM
MM slash DD slash YYYY

SHED Childrens Campus TRANSPORTATION AND RELEASE AGREEMENT 2021-2021

RELEASE INFORMATION I give my permission for my child to be released from SHED Children’s Campus at the end of the day to my spouse and/or to the following people. If no one other than you or your spouse is authorized, please indicate by writing NO ONE next to the NAME.
Full Name*
Full Name*
Full Name
Full Name
(If you filled in this line, please speak with one of the directors.) I understand that unless otherwise notified, SHED Children’s Campus shall assume that all natural or adoptive parents or legal guardians of the enrolled child or children shall have equal access to the records kept by SHED Children’s Campus regarding the enrolled child or children. I understand that unless SHED Children’s Campus is provided with a certified copy of an order from a court of competent jurisdiction which expressly states otherwise, either natural or adoptive parent or legal guardian may visit or pick up the enrolled child or children on an unrestricted basis during the normal hours of operation during the day. I understand that if a child is not to be released to one of his/her parents, SHED Children’s Campus must have a certified copy of the court order and a photograph of the person in our records.
Consent*

SHED After School Only

Consent*

In the unusual event that my child should take the bus home by mistake instead of coming to Kids Club, this is the name of a neighbor who might be home and who could be contacted:

Name
Address

Caterpillars, Monarch, Springboard & Nature Based K ONLY

My child will arrive & be picked up by parent/guardian:
Consent*
MM slash DD slash YYYY

SHED Childrens Campus FAMILY INFORMATION FORM 2021-2022

Parent/Guardian*
Parent/Guardian
Address if different*
Address if different
Employer/Place of Work Address
(if not applicable write N/A)
Employer/Place of Work Address
(if not applicable write N/A)
Do either of you work for a large corporation?*
(if not applicable write N/A)
(if not applicable write N/A)
Does your child have siblings?*
Name*
(if not applicable write N/A)
(if not applicable write N/A)
Name
(if not applicable write N/A)
(if not applicable write N/A)
(if not applicable write N/A)

SHED After School Only

Do we have permission to speak with the school adjustment counselor if we feel it is warranted?*
Does your child have an I.E.P.?*
If yes, please give a copy to Kid’s Club.
(if not applicable write N/A)
(if not applicable write N/A)
(if not applicable write N/A)
(if not applicable write N/A)
(if not applicable write N/A)
(if not applicable write N/A)
MM slash DD slash YYYY

SHED Childrens Campus FIRST AID AND EMERGENCY MEDICAL CARE, TRIPS AND PHOTOS AUTHORIZATION AND CONSENT FORM 2021-2022

Child's Name*
MM slash DD slash YYYY
Consent*
(if not applicable write N/A)
(if not applicable write N/A)

Emergency contacts (In order to be contacted)

Name*
Address*
Name*
Address*
Name
Address
Trips, Photos, Sunscreen and Bug Spray
I hereby authorize SHED Children’s Campus to allow my child to participate in the following: (please check all that you agree to)
MM slash DD slash YYYY

SHED Childrens Campus FINANCIAL AGREEMENT FORM 2021-2022

Consent*
I would like to receive a dependent care receipt for my tuition payment each month?*
Consent*
Please enter below the dollar amount of your monthly fee.
MM slash DD slash YYYY

SHED Childrens Campus 2021-2022 Child Medical Alert Form

If your child has an allergy/medical condition, please fill out this form.
Child's Name
In helping us appropriately and safely deal with a situation involving your child in this concern, please complete the following:
MM slash DD slash YYYY

Tooth-brushing Authorization or Waiver

Our licensing Agency, EEC has established a new policy regarding tooth-brushing. The policy states that if a child is in a program for more than 4 hours and if he/she eats a meal while at the program, then the child should have the opportunity to brush his/her teeth. Parents may, however, sign a statement indicating that their child does not need to brush while at the program.
Please choose one of the following:*
MM slash DD slash YYYY

SHED, INC. Permission Form for Use of Minor's Picture On the Internet

(A minor is any person 17 years of age and younger.) This letter is a request for permission to use photographs of your child on the: • Official SHED, Inc. Web Site on the Internet • SHED, Inc. Facebook, Instagram & Twitter page on the Internet • In SHED, Inc. promotional literature. The images are used on the Internet to promote a wide range of activities, however; the use of images is strictly controlled to best assure safety and confidentiality. Images displayed on the Internet will not be identified by name or any other identifying information. Please return the form on the back to indicate that your child's picture may or may not be used on the Internet. This permission will stay in effect until canceled by the parent or guardian. If you wish to cancel your permission and have your child's picture(s) removed, please contact the Webmaster at 978-684-5055 (Linda) and the pictures will be removed. Allow 3-5 working days for removal. Thank you for your cooperation. Linda Shottes-Bouchard Executive Director SHED Inc. 65 Phillips Street ~ Andover, MA 01810 ~ 978-684-5055 ~ FAX 978-636-4800 ~ www.shedchildrenscampus.org

SHED, Inc. Permission Form for Use of Minor's Picture On the Internet

Consent*
Child's Name*
Acknowledgement (if you consented yes)
MM slash DD slash YYYY

MEDICAL EMERGENCY TREATMENT:

I hereby give Kids Club permission to administer basic first aid and/or CPR to my child, and/or take my child, to a hospital and to secure medical treatment when I cannot be reached or when delay would be dangerous to my childs health.
MM slash DD slash YYYY

Dear Families.

SHED Children’s Campus is a wonderful family unit for all of us. We understand that family life is busy – filled with responsibilities, obligations, home life, school & work life, play and all of the fantastic extras. We are honored to be a part of your life and we recognize that some of your children’s time here comes with guidelines. We hope this form will help define some of those responsibilities. There are many extra days to sign up for, times to be here by, phone calls to make, etc.
Child's Name*
Here is a list of some of the things we ask you to remember:*
By checking the box you acknowledge acceptance of the following terms:
SHED After School & Springboard ONLY
MM slash DD slash YYYY

SHED Children’s Campus Family Contact List Authorization 2021-2022

The SHED Childrens Campus Contact List will contain the names, addresses, telephone numbers, email addresses, and parents names of all the students in the program whose families wish to participate. The contact list will be broken down by program (Monarch, Springboard to Kindergarten, Kids Club). Once compiled, a copy of the list will be distributed to each family. All parents should complete the bottom portion of this form indicating their wishes concerning the directory. Please return it with your other enrollment forms ASAP so we may expedite the directory distribution in the fall.
Would You like to include your child, in the Family Contact List?*

If you answered yes, please fill out the below fields:

You have my permission to print the following information:
Child's Name
Guardian Name
Address
Guardian Name
Address

Caterpillars, Monarch & Springboard ONLY SHED Childrens Campus 2022-2023 Developmental History

Child's Name
MM slash DD slash YYYY

Personal History

Any difficulties speaking?
Does your child see a counselor/therapist?

Health

Eating

Toilet Habits

Does child indicate his/her bathroom needs:
Does child have accidents?

Sleeping Habits:

Does child still take naps?

Social Relationships:

Has child had other child care experiences?
Is he/she/they frightened by...
Please check all that apply.
MM slash DD slash YYYY
Credit Card*
A down deposit of the yearly registration fee of $75 per child is required to submit the registration form.
American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Expiration Date
 
Billing Address*
This field is for validation purposes and should be left unchanged.