Kids & Main Drop-In Childcare Online Registration Form First Child Name*FirstMiddleLast Gender*Select valueMaleFemale Date of Birth* Age* Special Needs/Special Accommodations/Allergies & Other Medical Information ('None' if not applicable)* Second Child Name (2)FirstMiddleLast Gender (2)Select valueMaleFemale Date of Birth (2) Age (2) Special Needs/Special Accommodations/Allergies & Other Medical Information ('None' if not applicable)(2) Child Name (3)FirstMiddleLast Gender (3)Select valueMaleFemale Date of Birth (3) Age (3) Special Needs/Special Accommodations/Allergies & Other Medical Information ('None' if not applicable) (3) Child Name (4)FirstMiddleLast Gender (4)Select valueMaleFemale Date of Birth (4) Age (4) Special Needs/Special Accommodations/Allergies & Other Medical Information ('None' if not applicable)(4)1/4Next First Parent/Guardian Name*FirstLast Address* Street Address City State / Province / Region Postal / Zip Code Email (First Parent/Guardian)* Home Phone - First Parent/Guardian Mobile Phone - First Parent/Guardian* Second Parent/Guardian NameFirstLast Address - (if different) Street Address City State / Province / Region Postal / Zip Code Email (2) Home Phone (2) Mobile Phone (2)Previous2/4Next First Emergency Contact Name*FirstLast Emergency Contact Phone* Emergency Contact Name(2)FirstLast Emer. Contact Phone(2)Previous3/4NextACKNOWLEGEMENT OF PARENT HANDBOOK I acknowledge that I have received, read and agree to abide by the program guidelines as set forth in the Kids & Main Drop-In Childcare PARENT HANDBOOK. I understand that my child(ren) may be dismissed from Kids & Main Drop-In Childcare at the discretion of Management with no refunds for any violation of the terms of Kids & Main Drop-In Childcare as outlined in the PARENT HANDBOOK.NOTICE OF LICENSE & INSURANCE STATUSKids & Main Drop-In Childcare is a legally license-exempt child care program. This means we are not licensed, nor are we required to be licensed, by the State.We must, however, meet specific requirements set by the State to remain a legally license-exempt program. To remain compliant with State requirements, Kids & Main Drop-In Childcare must adhere to the following guidelines:Maintain attendance records for all children. Maintain parental acknowledgement forms and atteance records on-site while a child is enrolled and for one year after a child is no longer enrolled.Make all records available to Bright from the Start upon request.Notify Bright from the Start in writing within five business days if our program stops operating, closes or loses accreditation.Comply with zoning, certificate of occupancy, fire inspection and health department requirements.Submit a new exemption application if there are material changes in the operation of the program, such as a change of location, changes in operating months, days and/or hours, or change in ages served. Questions regarding licenses exemption rules can be directed to Bright from the Start by:Email: CCSExemptions@decal.ga.govPhone: 404-657-5562Mail: Bright from the Start, GA Department of Early Care & Learning, 2 Martain Luther King Jr Drive SE, 670 East Tower, Atlanta, GA 30334Kids & Main Drop-In Childcare does maintain liability insurance coverage.CONSENTSI agree and consent to the following:My child will not be allowed leave the facility without being escorted by the parent(s), person(s) authorized by parent(s), or facility personnel. The person escorting the child to the facility must notify facility personnel in advance if anyone other than that person will be escorting the child from the facility. This information is communicated by notifying a Staff Member at check-in.I agree to inform Kids & Main Drop-In Childcare within 24 hours or the next business day after my child or any member of the immediate household has developed a reportable communicable disease as defined by the State Board of Health, except for life-threatening diseases that must be reported immediately to a local medical facility. I authorize Kids & Main Drop-In Childcare to send periodic informational and promotional emails to any email address provided during the enrollment process or any email address supplied to Kids & Main Drop-In Childcare by any other means. I understand I may unsubscribe from these emails at any time. I authorize Kids & Main Drop-In Childcare to use photos of myself and/or any child I have enrolled in the Kids & Main Drop-In Childcare for any promotional materials regarding the Playcare’s programs and services. Promotional materials bearing these photos or likenesses may be distributed to the public and posted on the Kids & Main Drop-In Childcare's website and other internet/online media websites. I understand no personally identifying information will be associated with these photos or likenesses unless I give a separate, express consent to Kids & Main Drop-In Childcare. I understand I may revoke this consent at any time by notifying a member of Management.Kids & Main Drop-In Childcare agrees to obtain written authorization from me before my child participates in routine transportation, field trips, special activities away from the facility, and water-related activities occurring in water that is more than two (2) feet deep. (Applicable during School’s Out! Day Camps only)The registration fee (non-refundable/non-transferable) is due at the time of registration. I understand that payment in full is due prior to services being rendered, and Kids & Main Drop-In Childcare maintains a strict ‘no refunds’ policy.I acknowledge it is my responsibility to keep my child’s records current to reflect any significant changes as they occur, e.g., telephone numbers, work location, emergency contacts, child’s physician, child’s health status, etc. It is also my responsibility to create, update and maintain an account through the Kids & Main Drop-In Childcare automated, 3rd party check-in/check-out vendor. I authorize the child care facility to obtain emergency medical care for my child when I am not available an/or as outlined in the Parent Handbook. I (We) shall assume responsibility for payment for services.I acknowledge receipt of the Kids & Main Playcare Parent Handbook. I have read and agree to adhere to the polices of Kids & Main Drop-In Childcare as outlined in the Parent Handbook, and understand that failure to adhere to any policies therein is grounds for immediate dismissal of all children I have enrolled in the Kids & Main Drop-In Childcare program without refund.ACKNOWLEDGEMENTS & CONSENTSYou must acknowledge and agree to all notices and consents as listed above to enroll any child(ren) for Kids & Main Playcare services. Acknowledgement of Parent Handbook*Select BelowAcknowledge Notice of License & Insurance Status*Select BelowAcknowledge Consents*Select BelowAcknowledgeELECTRONIC SIGNATUREBy typing your name below and submitting this form, you acknowledge the information provided is true and accurate. Your typed name serves as your signature for the submission of this form. Full Name* Email* Date* Registration Fee - Number of Children Registering (must match the number of children listed on form)*1 Child2 Children3 Children4 ChildrenFamilies can save money off the standard hourly rate by purchasing a prepaid package of hours. Packages are optional but are a great way to SAVE MONEY on drop-in childcare services.Packages have the following restrictions:Packages are assigned to one or more children on the parent/guardian's account and cannot be transferred or refunded.If you register a single child, purchase a SINGLE child package. A FAMILY package cannot be applied to a SINGLE child.Multiple children in the same family share the hours in the FAMILY package. For example, two children that check in for 4 hours will use 8 hours of a FAMILY package.Multiple children must check in at the same time to use the FAMILY package.Hours do not expire and are not eligible for refund or transfer after purchase. Package Options*NoneSINGLE Child Package 10 hours - $85SINGLE Child Package 20 hours - $170FAMILY Package 10 hours - $75FAMILY Package 20 hours - $145 Total Card number* Expiration date123456789101112Month / 20202021202220232024202520262027202820292030Year CVC* Name* Zip code*SubmitResetPrevious4/4Next Offline Registration Prefer offline enrollment? Register at the counter before or during your first drop-in!