Author: ShanaA

Date of enrollment: ____________First Date of Service____________
Initial of staff that received form:___________

Monte Vista Kids Connection
Membership Form

Basic Information
Youth’s First Name:_______________ Middle Initial: _____ Last :
Gender: M F Ethnicity:______________________ Date of Birth: / /
Address:
City:__________________________________ State:________________ Zip:________
Parent/guardian Name:____________________________________________________________________
Home #:(_____)___________ Cell #: (____)_____________ Work #: (____)___________
Parent/guardian Name:________________________________________
Home #:(_____)___________ Cell #: (____)___________ Work #: (____)____ ___

General Information
Does your child have permission to walk home: ______Y _____N
Does your child have permission to check themselves out?___Y____N
If so please specify:
Swimming Level: ____ Beginner _____ intermediate ________ Advance
Do you give permission for your child to be used in MVKC’s public relations
materials: ______Y ______N

School Information
Name of School:
Current Teacher: Grade:______
Do you want your child to complete all homework at Kids Connection each day?
Does your child have any special learning needs we should be aware of?

Emergency Contact
Name:______________________________________________________________________
Home #: (____)____________ Cell #: (____)____________ Work #: (_____)_________
Relationship to Member:____________________________________________________
Name:______________________________________________________________________
Home #: (____)____________ Cell #: (____)____________ Work #: (_____)_________
Relationship to Member:____________________________________________________
Name:______________________________________________________________________
Home #: (____)____________ Cell #: (____)____________ Work #: (_____)_________
Relationship to Member:____________________________________________________

Person Authorized to Pick Up Your Child
Name:_____________________________________ Phone #: (_____)_______________
Name:_____________________________________ Phone #: (_____)_______________
Name:_____________________________________ Phone #: (_____)_______________
Name:_____________________________________ Phone #: (_____)_______________
Name:_____________________________________ Phone #: (_____)_______________
Name:_____________________________________ Phone #: (_____)_______________

Person UNATHORIZED to Pick Up Your Child
Name:_____________________________________ Reason: ______________________
Name:_____________________________________ Reason: ______________________
Name:_____________________________________ Reason: ______________________
Name:_____________________________________ Reason: ______________________
Please provide MVKC Director with a copy of the court order if applicable.

Medical Information
Name, Address, and Phone # of Your Child’s Doctor:
Name, Address, and Phone # of Your Child’s Dentist:

Medical Information Continued…
Name and Phone # of Your Child’s insurance Company:
Hospital of Preference:
Medical conditions:
Physical limitations:
Dietary limitations:
Allergies (please explain type of reaction):
Is your child on any medications? ( Explain)
Is your child fully immunized: __________Y ____________N
Please read thoroughly and ask a staff member if you
have any questions
I authorize all medical and surgical treatment, X-ray, laboratory, anesthesia, and other
medical and /or hospital procedures as may be performed or prescribed by the attending
physician and/or paramedics for my child and waive my right to informed consent of treatment. This waiver applies only in the event that neither parent/guardian can be reached or in case of emergency.
Parent/guardian’s signature: Date:__________

In consideration of my child’s membership and participation in The Monte Vista Kids Connection, I as the parent/guardian of the above named minor do herby release the MVKC from liability to me, my child, and the child’s personal representatives, assigns and heirs for all claims and damages which my child or I may have against the MVKC and /or its sponsors resulting from participation in or connection to a MVKC related activity. I hereby authorize the MVKC, as my agent, to secure medical treatment as deemed necessary, and will, on behalf of said minor, assume and pay all expenses associated with such treatments in the event that an accident, illness or other incapacity. I will ensure that my child is fit and sufficiently trained to participate in the programs of the MVKC. I permit the MVKC to utilize surveys/testing to evaluate the effectiveness of the MVKC programs and hereby waive all rights of compensation for said use. I understand that the MVKC is not responsible for the time or manner in which my child arrives or leaves the MVKC and I also understand that the MVKC is not responsible for the lost or stolen items or personal belongings.
Parent/guardian’s signature: Date:

Childs Name
Monte Vista Kids Connection
Verification of TANF Eligibility for Funding Purposes.
Please fill out all information completely; failure to do so will result in having to pay for services.
Race:
( ) Hispanic ( ) Not Hispanic
Ethnicity:
( ) White ( ) Black ( ) Asian ( ) Multi-ethnic ( ) Other
Annual Income:
( ) less than $75,000 ( ) more than $75,000
Are you a U.S Citizen?
( ) Yes
( ) No
I certify that all information I have completed is true and is to the best of my knowledge. I understand that MVKC will receive TANF funding based on the information I give. I understand that MVKC may verify this information.
Parent/Guardian Signature Date

n order for membership to be accepted, you must make sure you have all the proper information included.(Please initial that you have included all necessary information.)
Parent Initial Document Staff initial

Immunization Records
Permission Slip
Transportation Agreement
Reduced Lunch Form
Parent Child Agreement
Transportation Fee
Allergy Packet if needed