20/21 Kids Club Registration Form

Choose OPS Elementary Kids Club Site: *

Child Information (Legal):

Child First Name: *

Child Last Name: *

OPS Student ID

Date of Birth (mm/dd/yyyy) *

Gender: *

Female
Male

Grade: *

Have you or a sibling attended Kids Club before? *

Yes
No

Primary Account Guarantor

Account Guarantor First Name: *

Account Guarantor Last Name: *

Guarantor Relationship to Student: *

Guarantor Address: *

Address Line 1

City

State

Zip Code

Guarantor Cell Phone: *

Guarantor Home Phone:

Guarantor Employer:

Guarantor Email: *

Email

Confirm Email

I would like to add a second guarantor. *

Yes
No

Account Guarantor Name 2:

First

Last

Relationship to Student 2:

Address 2: *

Address Line 1

City

State

Zip Code

Cell Phone 2:

Home Phone 2:

Email 2:

Email

Confirm Email

Emergency & Authorized Pickup Contact Information: (Minimum of 2 Required)

Contact #1

Name: *

First

Last

Authorized Pick Up: *

Yes
No

Relationship to Student: *

Best Contact Phone: *

Contact #2:

Name: *

First

Last

Authorized Pick Up: *

Yes
No

Relationship to Student: *

Best Contact Phone: *

Contact #3:

Name

First

Last

Authorized Pick Up:

Yes
No

Relationship to Student:

Best Contact Phone:

Contact #4:

Name

First

Last

Authorized to Pick Up:

Yes
No

Relationship to Student:

Best Contact Phone:

Additional Information

Consent to contact a physician in case of emergency: *

Yes
No

Omaha Public Schools Foundation Kids Club will not be responsible for taking any child to the clinic or ER for emergency/medical treatment. Kids Club will contact 911 in the event of a medical emergency and will immediately contact the parent or guardian of the child.

Family Physician Name: *

Physician's Phone: *

If no, what procedure should be taken: *

Current health concerns Kids Club should be aware of: *

Medication(s), if any: *

This list of medications should also be given to OPS the school nurse. Kids Club and OPS do not share medical information.

List any allergies and/or intolerance to food, insect bites, stings, or other factors that result in a medical reaction: *

Please give clear instructions in the event of an exposure to the factor.

Special Concerns: *

List glasses, hearing aids, crutches, or other considerations.

Any activities in which your child may NOT participate: *

$30 Registration Fee (Non-Refundable)

Make check/money order payable to Omaha Public Schools Foundation. Cash payments accepted at Main Office ONLY, 3861 Farnam St., Omaha, NE 68131.

Consent & Release Permission

I give my permission for the Omaha Public Schools Foundation to include my child, who attends the OPSF Pre-K Program, in I give my permission for the Omaha Public Schools Foundation to include my child, who attends the OPSF Kids Club, in photographs, videotapes, and broadcasts used for publicity and promotion of the Omaha Public Schools Foundation.

I consent for my child to be photographed or videotaped. *

Yes
No

Signature *

Typed Name *

First

Last

By signing this I agree to abide by the policies stated in the Parent/Guardian Handbook. I understand this is a parent pay program and I personally guarantee and promise to pay any fees that are due to the OPSF Kids Club Program. I agree to sign my child/children in and out when entering and/or leaving OPSF Kids Club program and failure to do so will result in program termination.

As primary guarantor, *

I understand that my child's registration is not valid unless account is in good standing. and $30 registration fee has been paid.

Submit payment via website or call 402.502.3032 to pay over the phone.

I understand that access to Kids Club will not begin until OPS resumes full time in person learning on Tuesday, February 2nd, 2021. Kids Club tuition is charged as weekly flat rate for the reserved spot and is not based on attendance, *

Choice 3

Guarantor 1 Signature: *

Guarantor 1 Name: *

First

Last

(Account Name - Guarantor 1)

As a secondary guarantor, I understand this registration is not valid until signed, registration fee of $30.00 paid, and any previous balance paid. (copy) *

I understand.

Guarantor 2 Signature: *

Guarantor 2 Name: *

First

Last

(Account Name - Guarantor 1)