To register for the 2019-2020 Kindergarten program print this form or complete registration below. How did you hear about us?* Web Search Friend/Word of Mouth Flyer/Brochure Mailer School District Yellow Pages Social Media Advertisement Yard Sign or Banner Other Location (School)*Erpenbeck ElementaryNew Haven ElementaryYealey ElementaryKelly ElementaryStephens ElementarySouthgate ElementaryMy child also needs care (2 days per week minimum)Extended Education - $78/week Before School Program (2 day minimum) $5.50/day, $26/week After School Program (2 day minimum) $11/day, $51/week EE + After School (5 days) - $124/week EE+ Before & After School (5 days) - $150/weekBefore the start of the school day (Before School Program) Monday Tuesday Wednesday Thursday Friday After the end of the school day (After School Program) Monday Tuesday Wednesday Thursday Friday Morning and or Afternoon Sessions* Children, Inc. Morning EE Session Children, Inc. Afternoon EE Sesion Select the Extended Education program in which you would like to enroll your kindergarten child. Full time, M-F only. Today's Date* Please enter your desired start date ***NOTE: Start date MUST be 2 full business days from today's date**** MM DD YYYY Your child's start date must be at least two business days after registration date. For registrations submitted after 12:00PM, the following business day will be considered the registration date.Are you eligible for:*[none]Free LunchReduced LunchDo you receive state child care assistance?*YesNoState Case/Social Worker (if applicable):Child's Name* First Last Gender* Female Male RaceDate of Birth* MM DD YYYY Parent/Guardian Primary Mailing Address and Contact InformationThis information will be automatically entered into the Community Safe interactive system. When there are situations which require immediate attention you will be notified via email, voicemail, or text message. This system will give you updates, closings, delays, and reminders. It is very important that we keep accurate information so that we can reach you in case of an emergency. It is vital that you provide up-to-date contact information. If any of your information changes please contact us at (859) 431-2075 and ask for Diana.Name* First Last Employer*Work PhoneCell Phone*Email Primary Home Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary County*Primary Home Phone*Parent/Guardian Secondary Contact InformationThis information will be automatically entered into the Community Safe interactive system. When there are situations which require immediate attention you will be notified via email, voicemail, or text message. This system will give you updates, closings, delays, and reminders. It is very important that we keep accurate information so that we can reach you in case of an emergency. It is vital that you provide up-to-date contact information. If any of your information changes please contact us at (859) 431-2075 and ask for Diana.Name* First Last Employer*Work PhoneCell Phone*Email May we give information regarding your child to parent/guardian #2?* Yes No Emergency Contact 1 other than parent/guardian listed above* First Last Primary Phone*Secondary PhoneEmergency Contact 1: Permission to Pick Up?* Yes No Emergency Contact 2 other than parent/guardian listed above First Last Primary PhoneSecondary PhoneEmergency Contact 2: Permission to Pick Up? Yes No Is there any additional information you'd like to share that would help us better serve your child? For example, any special physical or emotional needs, behavioral issues, health concerns or allergies? If you have any other questions, comments, or issues please use this space for those. Thanks!Immunization Certificate* I understand that a current Immunization Certificate must accompany this enrollment and I agree to provide one during my child's first week of attendance. Name of Physican*Physician Phone Number*Preferred Hospital* Click here to grant Emergency Medical Authorization CommentsThis field is for validation purposes and should be left unchanged.