SHED Fall Registration Form – SHED Childrens Campus

SHED Registration Form

"*" indicates required fields

Child's Name*

First Last

Name He/She/They like to be called

Birth Date*

Address*

Street Address Address Line 2 City ZIP / Postal Code

Home Phone*

Child's Cell Phone (if not applicable write N/A)*

School*

Grade Entering*

Program Information

All programs require a 30-day notice to make any schedule adjustments.

Program Start Date*

Please Select the SHED Program You're Registering For:*

Caterpillar Toddler Program

Monarch Preschool (you MUST call to register for this program)

Springboard to Kindergarten (you MUST call to register for this program)

Forest Kindergarten

SHED Before School

SHED After School

Drop-in

Parent/Guardian Name*

First Last

Business Phone*

(if not applicable write N/A)

Cell Phone*

Email*

Parent/Guardian Name

First Last

Business Phone

Cell Phone

Kids Club ONLY:

Is there documentation of a physical exam, immunization record, and lead screening on file at your child’s school?

Yes

Please list any special limitations or concerns you or your child may have including:

dietary restrictions, allergies, chronic health conditions, ect.

Child Identifying Information

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

Child's Eye Color*

Childs Hair Color*

Childs Skin Color*

Height*

Weight*

Sex*

Identifying Marks (if not applicable write N/A)*

SHED Before & After School Programs

Please select the days attending

Before School (7:30 am-9am):

After School (3:30-6pm):

Full Time Afternoons:

Five days a week

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

Please select the extended time and day if applicable.

Forest Kindergarten

Mon - Fri 8:30 AM - 3:30 PM

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

Mon - Fri 8:30 AM - 3:30 PM

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)

Five days a week

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)

Five days a week

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

Signature*

Date*

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*

First

Phone*

Relationship*

Full Name*

First

Phone*

Relationship*

Full Name

First

Phone

Relationship

Full Name

First

Phone

Relationship

If there is anyone who is not allowed to pick up, please indicate below and speak with an Administrator. THIS PERSON MAY NOT PICK UP MY CHILD (if not applicable write N/A)*

(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*

I fully understand and agree to the TRANSPORTATION AND RELEASE AGREEMENT

I understand that people who are listed under “Emergency Contacts” (next page) are authorized by me to pick up my child at SHED Children’s Campus in an “emergency” situation.

I understand that any other transportation requests must be stated in writing and maintained in the child’s file or the above plan must be implemented. This permission is valid from date of signature to the end of that program year.

I understand that SHED Children’s Campus will assume full responsibility for my child from the time he/she arrives
at the program until my child leaves the program according to the written instructions for departure.

SHED After School Only

Consent*

I fully understand and agree to the following:

If my child should miss the bus, I give permission for the Kids Club teacher to drive him/her from his/her/their neighborhood school to Kid’s Club.

I understand that my child must be picked up from Kids Club by 6:00 PM. If he/she/they are not picked up, Kid’s Club will impose strict late fees according to the late fee policy in the handbook.

I understand that I must notify Kids Club daily if my child will be absent on a regularly scheduled day.

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

First Last

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Caterpillars, Monarch, Springboard & Nature Based K ONLY

My child will arrive & be picked up by parent/guardian:

Yes

If your child will not be dropped off or picked up by parent, please indicate directions:

Consent*

I agree to the following policies:

If there is an alternative drop-off or pick-up person, I will call or email the directors to let them know.

If there is an alternate drop-off or pick-up person, I will call or email the directors to let them know.

Signature*

Date*

SHED Childrens Campus FAMILY INFORMATION FORM 2021-2022

Parent/Guardian*

First

Relationship to Child*

Cell Phone*

Business Phone (if not applicable write N/A)

Address if different from your child:*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Occupation (if not applicable write N/A)

Employer (if not applicable write N/A)*

Work Hours (if not applicable write N/A)

Employer/Place of Work Address

(if not applicable write N/A)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Parent/Guardian

First

Relationship to Child

Cell Phone*

Email*

Business Phone (if not applicable write N/A)

Address if different from your child:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Occupation (if not applicable write N/A)

Employer (if not applicable write N/A)

Work Hours (if not applicable write N/A)

Employer/Place of Work Address

(if not applicable write N/A)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Do either of you work for a large corporation?*

Yes

Who?*

(if not applicable write N/A)

Which Corporation?*

(if not applicable write N/A)

How did you hear about SHED Children's Campus?*

Does your child have siblings?*

Yes

Name*

First

(if not applicable write N/A)

Age*

(if not applicable write N/A)

Name

First

Age

Siblings child care program*

(if not applicable write N/A)

Phone

Please list any special interests or abilities your child may have:*

(if not applicable write N/A)

Is there a therapist or counselor that your child sees?*

(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?*

Yes

Does your child have an I.E.P.?*

If yes, please give a copy to Kid’s Club.

Yes

Are there any medications your child takes on a regular basis? What does he/she take and why?*

(if not applicable write N/A)

Please indicate any eating or sleeping problems:*

(if not applicable write N/A)

Please list any child care or group experiences that your child has had prior to SHED Childrens Campus:*

(if not applicable write N/A)

Please describe your childs personality:*

(if not applicable write N/A)

Please indicate what languages are spoken at home:*

(if not applicable write N/A)

Is there any other information you would like us to know about your child?*

(if not applicable write N/A)

Signature*

Date*

SHED Children's Campus FIRST AID, CPR, EMERGENCY MEDICAL CARE, TRIPS AND PHOTOS AUTHORIZATION AND CONSENT FORM 2021-2022

Child's Name*

First Last

Date of Birth*

Consent*

I agree to and fully understand the following policies.

I understand that the SHED Children’s Campus staff are trained in the basics of First Aid & CPR and I authorize them to give my child first aid when appropriate.

I understand that every effort will be made to contact me in the event of an emergency requiring medical attention for my child. I hereby authorize SHED Children’s Campus to call my physician and/or secure necessary medical care in case of illness or accident, to administer first aid, and to otherwise act on my behalf when I cannot be reached and/or a delay would be dangerous to the protection of my child. If I cannot be reached, I authorize SHED Children’s Campus to accompany my child in an ambulance transport to the nearest hospital for medical treatment including administration of anesthesia if surgery is advised by a physician.

Name of Hospital*

Child Physicians name:*

Phone*

Physicians Address:*

Health Insurance Coverage:*

Policy #*

Child’s Allergies:*

(if not applicable write N/A)

Chronic Health Conditions*

(if not applicable write N/A)

Emergency contacts (In order to be contacted)

Name*

First Last

Relationship to Child*

Phone*

Address*

Street Address Address Line 2 City ZIP / Postal Code

Name*

First Last

Relationship to Child*

Phone*

Address*

Street Address Address Line 2 City ZIP / Postal Code

Name

First Last

Relationship to Child

Phone

Address

Street Address Address Line 2 City ZIP / Postal Code

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)

Field trips (special permission required for bus trips)

Walks (local, library, downtown, AVIS trails, Phillips Academy Bird Sanctuary, etc.)

Photos (for SHED Children’s Campus / Kid’s Club use to release to newspapers)

Photos (for SHED Children’s Campus / Kid’s Club to use on our website & Facebook / Instagram page

I hereby authorize SHED Children’s Campus to apply sunscreen as needed

I hereby authorize SHED Children’s Campus to apply bug spray as needed

Signature*

Date*

SHED Childrens Campus FINANCIAL AGREEMENT FORM 2022-2023

Consent*

I fully understand and agree to SHED's following financial terms

I understand there is an annual Facility Fee ($300 for 1 child / $500 per family).

Those in the Kid’s Club before school ONLY are not responsible for a facility fee

I understand that SHED Children’s Campus registration fee is due with registration and is non-refundable.

SHED Children’s Campus does not bill; payment is due the first day of each month. Checks should be made payable to SHED Inc. Checks can be mailed or dropped off. Payment can be made by credit card on our website.

I understand that if my payment is not received by the 5th of the month it is due, I will be charged a $30.00 late fee.
Unpaid late fees will accrue on the account.

I understand that I may only register my child for the following year if my account is up to date and clear of any debts.

I will give 30 days' notice, in an email, prior to changing my child’s schedule or to withdrawal from the program.

I understand that I must consider my needs very carefully and no schedule changes may be made between August 1st and the end of September. After that, I may request changes which will be honored by SHED Children’s Campus if possible.
I further understand that I can only make 3 changes to my child’s schedule during the school year; after that, there will be a $30 processing fee per family per schedule change.

I understand that SHED Children’s Campus is open according to the published SCC calendars. SCC is closed on most holidays, and during the Winter Holiday break & 4th of July week & for a staff professional development day in March. SCC is open on a sign-up, additional fee basis ($80.00 per day) during the other school vacation weeks (February and April) and the In-Service & half days.

I understand there is a $10 late fee – per day if I sign up for a vacation or in-service day after the deadline.

I understand that SHED Children’s Campus reserves the right to close during the day on a snow day if the weather is deemed unsafe or very extreme. SCC will email families & post a message on our voicemail with opening or closing decisions.

I understand that in the event of any absences or personal vacations during the program hours, I am still responsible for fees for time reserved, not actual time spent at the Program.

I understand that all children are accepted into SHED Children’s Campus on a two-month trial basis. If SHED Children’s Campus cannot accommodate the needs of my child, SHED Children’s Campus will provide help in finding another placement.

I understand that if my child is going to be absent I need to call or email SHED Children’s Campus to let them know.

I understand I need to read the Parent Handbook (can request a copy from the directors) & be responsible for following the guidelines it contains.

I agree to adhere to the stated policies and procedures of SHED Children’s Campus and give my child permission to participate fully in this program.

I would like to receive a dependent care receipt for my tuition payment each month?*

Yes

Consent*

I agree to the following policy.

I understand tuition is divided evenly over 10 months and I am responsible for payment of monthly fees.

My Monthly Payment Amount*

Please enter below the dollar amount of your monthly fee.

Signature*

Date*

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

First Last

Has an Allergy/Medical Condition

In helping us appropriately and safely deal with a situation involving your child in this concern, please complete the following:

How do you normally handle this concern?

How would you like us to respond if this concern arises?

Is there anything that triggers or complicates this situation?

Is there anything that your child should avoid doing?

What is it / Are there any medical limitations that we should be aware of?

Are there things that you find can make the situation worse?

Are there things that you find can make the situation better?

Are there any non-emergency situations that you would prefer to be phoned by a staff member to alert you to a given situation?

Signature

Date

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:*

Yes, I would like my child to brush his/her teeth while at Kid’s Club (full days and vacation weeks). I will supply a toothbrush and a tube of toothpaste for his/her/their use. I will label both the toothbrush and the toothpaste with my child’s name. I will replace the toothbrush every 3 months.

No, I do not want my child to brush his/her/their teeth while at SHED Children’s Campus.

Signature*

Date*

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*

Yes, my childs picture may be used

No, my childs picture may not be used on the Internet

Child's Name*

First Last

Acknowledgement (if you consented yes)

I have read the following:

As the parent or legal guardian, I grant SHED, Inc. permission to use my child's picture on the

Official SHED, Inc. Web Site on the Internet,
SHED Facebook or Instagram page on the Internet
In SHED promotional literature.

I understand that at any time, I may have my child's picture removed by contacting the SHED, Inc. Webmaster. It is
agreed that the use of my child’s photograph or photographic image shall in no way be used in any other forum other than for official SHED, Inc. business.
I hereby waive any right that I may have to inspect or approve the finished product and the advertising copy and/or other matter that may be used in connection therewith or the use to which it may be applied.
I do hereby release, acquit and forever discharge SHED, Inc., its officers, employees, attorneys, representatives, insurers and assigns from any and all demands, cause of action and/or judgments of whatsoever nature of character, past or future, known or unknown, whether in contract or in tort, whether for personal injuries, property damage, payments, fees, expenses, accounts receivable, credit, refunds, or any other monies due or to become due, or damages of any kind or nature, and whether arising from common law or statute, arising out of, in any way, the use of my photograph or photographic image for official SHED, Inc. business through its Website, Facebook page, Patch or SHED, Inc. promotional literature.
This release contains the entire agreement between the parties and shall be binding upon and inure to the benefit of the successors and assigns of the undersigned.

Signature*

Date*

MEDICAL EMERGENCY TREATMENT:

I hereby give SHED Children's Campus permission to administer basic first aid and/or CPR to my child, and/or take my child, to a hospital to secure medical treatment when I cannot be reached or when delay would be dangerous to my childs health.

Signature*

Date*

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*

First Last

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:

I understand if my child will be absent from SHED Children’s Campus, I need to let SCC know about this absence by phone call or email.

I understand if I need to make a change in my child’s schedule, I must contact the directors. There is a 30 day notice before tuition can be reduced.

SHED After School & Springboard ONLY

I acknowledge and accept the following:

I understand if I need my child to attend SHED Children’s Campus on a half-day, in-service day, or vacation day, I must sign up for this day beforehand. I must sign up EVEN if it is my child’s regularly scheduled day. Sign-ups are available at least 2 weeks prior to the day. I can sign up by phone call, on the sign-up sheet in the front hall, or by email

I understand I must pay for the half days or in-service days by the deadline (usually a week before the date).

I understand if I sign up for the half days, in-service days, or vacation days after the deadline, space is not guaranteed & there is a $10 late fee.

I understand I must cancel a sign up 48 hours in advance or I will be responsible for the fee.

I understand Kid’s Club closes at 6 pm. If I arrive later than 6 pm, minutes will start accruing towards the 15 minute grace time allotted each year. Any minute after that grace time equals $2 in late fees

I understand SHED Children’s Campus is dedicated to caring for my child as an individual and will find ways to enhance my child’s imagination & curiosity.

SHED Children’s Campus understands you have entrusted us with your most precious loved ones. We will do our very best each and every day to respect and appreciate the trust you have placed in us.

Warmly,
SHED Children’s Campus Administration & Educators

Signature*

Date*

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?*

Yes

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

You have my permission to print the following information:

Child's Name

First Last

Guardian Name

First Last

Home Phone

Cell Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Guardian Name

First Last

Home Phone

Cell Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

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

Child's Name

First Last

Birth Date

Personal History

Any complications at birth?

Any developmental delays (sitting, crawling, walking)?

Any difficulties speaking?

Yes

Any other languages spoken at home?

Does your child see a counselor/therapist?

Yes

For what reason?

Any other helpful information?

Health

Any serious illness or hospitalization?

Any physical disabilities/limitations?

Any allergies?

Any medications given regularly?

For what?

Eating

List any eating problems:

Food allergies?

Favorite Foods:

Any food refused?

Toilet Habits

Does child indicate his/her bathroom needs:

Yes

Sometimes

Does child have accidents?

Yes

Sometimes

Are there any specific words of which we should be aware to indicate bathroom needs?

Sleeping Habits:

Does child still take naps?

Yes

Sometimes

What time does child get up in the AM

What time does child go to bed?

What does child take to bed?

Social Relationships:

Has child had other child care experiences?

Yes

Where?

How long did he/she/they attend other program(s)?

Is your child involved in other outside activities?

How does your child relate to strangers?

What is your child’s favorite toy?

Is he/she/they frightened by...

Please check all that apply.

Other?

Does your child have any pets?

How would you describe your child?

Signature*

Date*

Registration Fee*

Price:

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

Card Number

Expiration Date

Security Code Cardholder Name

Billing Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Comments

This field is for validation purposes and should be left unchanged.

SHED Registration Form

Program Information

Child Identifying Information

SHED Before & After School Programs

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

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

Monarch Preschool

Caterpillars Toddler Program

SHED Childrens Campus TRANSPORTATION AND RELEASE AGREEMENT 2021-2021

SHED After School Only

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:

Caterpillars, Monarch, Springboard & Nature Based K ONLY

SHED Childrens Campus FAMILY INFORMATION FORM 2021-2022

SHED After School Only

SHED Children's Campus FIRST AID, CPR, EMERGENCY MEDICAL CARE, TRIPS AND PHOTOS AUTHORIZATION AND CONSENT FORM 2021-2022

Emergency contacts (In order to be contacted)

SHED Childrens Campus FINANCIAL AGREEMENT FORM 2022-2023

SHED Childrens Campus 2021-2022 Child Medical Alert Form

Tooth-brushing Authorization or Waiver

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

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

MEDICAL EMERGENCY TREATMENT:

Dear Families.

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

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

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

Personal History

Health

Eating

Toilet Habits

Sleeping Habits:

Social Relationships:

Call Us To Book A Tour

We'd love to have you join us while class is in session.
Please give us a call today to schedule your tour.

Join Our Mailing List

Find Us

Programs

Explore

Get In Touch

SHED Registration Form

Program Information

Child Identifying Information

SHED Before & After School Programs

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

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

Monarch Preschool

Caterpillars Toddler Program

SHED Childrens Campus TRANSPORTATION AND RELEASE AGREEMENT 2021-2021

SHED After School Only

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:

Caterpillars, Monarch, Springboard & Nature Based K ONLY

SHED Childrens Campus FAMILY INFORMATION FORM 2021-2022

SHED After School Only

SHED Children's Campus FIRST AID, CPR, EMERGENCY MEDICAL CARE, TRIPS AND PHOTOS AUTHORIZATION AND CONSENT FORM 2021-2022

Emergency contacts (In order to be contacted)

SHED Childrens Campus FINANCIAL AGREEMENT FORM 2022-2023

SHED Childrens Campus 2021-2022 Child Medical Alert Form

Tooth-brushing Authorization or Waiver

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

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

MEDICAL EMERGENCY TREATMENT:

Dear Families.

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

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

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

Personal History

Health

Eating

Toilet Habits

Sleeping Habits:

Social Relationships:

Call Us To Book A Tour

We'd love to have you join us while class is in session. Please give us a call today to schedule your tour.

Join Our Mailing List

Find Us

Programs

Explore

Get In Touch

We'd love to have you join us while class is in session.
Please give us a call today to schedule your tour.