Kinderfolk Clubhouse Registration Child Information * First Name Last Name Date of Birth * MM DD YYYY Allergies or Medical Conditions * Medical Needs (inhaler, EpiPen, medications etc.) * Is your child up to date on their recommended vaccinations? * Yes No Prefer not to say Parent/ Guardian Information * First Name Last Name Relationship to Child * Phone Number * (###) ### #### Email * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Second Parent/Guardian (if applicable) First Name Last Name Relationship to Child Phone Number (###) ### #### Email Emergency Contact (other than parents) * First Name Last Name Relationship to Child Phone Number (###) ### #### Authorized Pick-up List Please list all individuals (besides parents/guardians) authorized to pick up your child: First Name Last Name First Name Last Name First Name Last Name Getting to Know Your Child What are your child’s favorite activities, toys, or interests? How would you describe your child’s personality? Does your child have any fears, sensitivities, or strong dislikes? How does your child respond to transitions or changes in routine? What helps soothe or comfort your child when upset? Are there any family traditions, cultural practices, or values you’d like us to honor in the classroom? What are your hopes for your child’s experience at Kinderfolk Clubhouse? 1. Consent for Participation, I give permission for my child to attend Kinderfolk Clubhouse, a home-based preschool program led by Kira Davis. I understand that this program follows a play-based, child-led approach inspired by Reggio Emilia, Waldorf, Montessori, and Finnish pedagogy. Activities will include both indoor and outdoor play, art, nature exploration, sensory work, and social-emotional development. * I give permission for my child to participate in the program as described. 2. Emergency Medical Authorization, In the event of an emergency, I authorize Kira Davis to obtain medical treatment for my child, including emergency transportation if needed. * I authorize emergency care for my child in the event I cannot be reached. Doctors Name * First Name Last Name Doctors Phone Number * (###) ### #### Preferred Hospital 3. Assumption of Risk, I understand that participation in an active, play-based program—especially one that includes outdoor exploration—comes with inherent risks (e.g., minor scrapes, bug bites, sun exposure). I acknowledge that Kira Davis will take all reasonable precautions and provide attentive supervision, but cannot eliminate all risk. * I understand and accept the inherent risks of participation. 4. Waiver of Liability, I agree to release and hold harmless Kira Davis, her family, and the owners of the property at 405 N 300 W, Lehi, Utah, from any and all liability, claims, or demands arising from participation in Kinderfolk Clubhouse. This includes injury, illness (including communicable diseases), or personal property damage or loss. * I waive any liability against the provider and property owner. 5. Illness Policy Children must stay home if they show symptoms of illness, including but not limited to fever, vomiting, diarrhea, excessive coughing, or contagious conditions. Children may return once symptom-free for 24 hours (without the aid of medication). I understand this policy is in place to protect the health of all participants. * I agree to keep my child home when sick and follow the illness protocol. 6. Behavior Policy Kinderfolk Clubhouse is built on respect and connection. While occasional emotional outbursts are normal for young children, repeated unsafe or harmful behavior that does not improve with support may result in dismissal from the program. This includes ongoing physical aggression, refusal to follow basic safety guidelines, or behaviors that endanger others. * I understand the expectations for behavior and safety. 7. Field Trip & Neighborhood Walks, With a focus on nature-based learning, the program may include walks around the block or visits to nearby green spaces. All outings will be supervised with appropriate child-to-adult ratios. Parents will be notified in advance of any off-property excursions beyond the immediate area. * I give permission for neighborhood walks and local nature outings. 8. Emergency Equipment, If my child requires emergency medical devices (e.g., inhaler, EpiPen), I will provide clearly labeled devices and train the provider in their use. * I will provide all required emergency medications and instructions. 9. Minor Injuries and First Aid, I understand that minor injuries (e.g., scratches, bruises, bug bites) may occur. I consent to basic first aid being administered and to be notified of any such incidents. * I consent to basic first aid and injury communication. 10. Licensing Acknowledgement, Kinderfolk Clubhouse is a private preschool program and is not licensed through the state of Utah. The program follows best practices in safety, supervision, and early childhood education, but is not regulated by state licensing authorities. * I acknowledge that this is a private, unlicensed preschool program. 11. Tuition & Payment Policy Monthly Tuition: $390 (Tuesdays & Thursdays, 3 hours/day) One-Time Registration Fee: $75 (non-refundable) Tuition is due on the 1st of each month. A $15 late fee will apply to payments more than 3 days late. The fee reserves your child’s space and covers materials, planning, and a nutritious snack each day. Up to 3 cancellations per year initiated by the provider (due to teacher illness, weather, or emergency) are permitted without make-up or refund. After 3 such cancellations, families will be eligible for a make-up class (if available) or pro-rated reimbursement. * I understand and agree to the payment terms, late fee, and provider-initiated cancellation policy. 12. Photo/Media Consent Photos may be taken during class for the purposes of sharing updates with enrolled families or future marketing. No identifying details will be shared publicly without written permission. ☐ I give permission for my child to be photographed during class. ☐ I do not give permission for my child to be photographed. * I give permission for my child to be photographed during class. I do not give permission for my child to be photographed. Acknowledgement & Signature, I have read and agree to the above terms for participation in Kinderfolk Clubhouse. I understand this is a private, home-based preschool program. I voluntarily consent to my child’s participation. * Please type your name below to sign Thank you!
