FOR PROVIDER USE ONLY
1. Everyone must answer the following question. (Todos deben contestar la pregunta
3. EVERYONE must select ONE OR MORE of the following races regardless of how you answered question one. (TODOS deben seleccionar UNA O MAS de las siguientes razas sin importar cómo haya contestado la primera pregunta.)
In an effort to identify and best serve the needs of the families and children in the Summer Transition Program, we ask that you complete the following survey. The survey will assist the Transition Coach in planning activities throughout the six-week program.
Should your child become injured or ill while in the care of A Kid’s World and you are unable to be
contacted, A Kid’s World is authorized to secure medical attention as deemed necessary. By signing below
the parent acknowledges that A Kid’s World does not provide medical insurance to the children in our
program and the parent shall assume responsibility for any/all medical expenses. Also, by signing below you
agree to hold A Kid’s World and its staff members harmless to any claims that may arise during my child’s
enrollment in the program.
1. Call emergency medical team, if necessary
2. Call parent/guardian
3. Call alternate emergency contact, if necessary
4. Emergency medical team transport child to hospital, if necessary
5. A Kid’s World Representative will accompany child to the hospital
Hospital A Kid’s World Uses:
2151 West Spring Street
Monroe, GA 30655
If the child relocates to another school or the hours change, this form must be updated.
• In the event the designated location is unable to receive children they will be returned to AKW
• It is vital that AKW be notified of any changes in the above scheduled transportation.
• AKW will assume the above schedule of transportation will be followed unless we receive different
instructions from parents. Instructions should be received at AKW no later than 1hr prior to pick up time.
Parental Authorization. Except for first aid, personnel shall not dispense personnel shall not dispense
prescription or non-prescription medications to a child without specific written authorization from
the child’s physician or parent. Such authorization will include, when applicable, date; full name of
the child; name of the medication; prescription number, if any; dosage; the dates to be given; the
time of day to be dispensed; and signature of parent.
The USDA Food Program is a subsidized program that allows our center to provide high quality,
large portioned meals to our children without any additional cost to our families.
In order for our center to qualify for this program we must prove that at least 25% of our families
meet the “Free or Reduced” income standards. To do this we must maintain income verification
forms on all families that attend our center. Even if you do not feel like your income would help
us “qualify”, we still must maintain a verification form for your family. We must update our forms
Please feel sure that this information is maintained separate from children’s records and only
the management team had access to this information. This information is not used for any other
In addition, please complete all areas of this form! If your form is not filled out and signed, we
have to count your family as a paid family regardless of your income!
Thank you for your help and understand. Please feel confident in knowing that our center’s
participation in the USDA Food Program allows A Kid’s World to serve high quality meals to our
A Kid’s World
Social Security Number. If income is listed or completed in Part II, the adult completing the form must also list the last four
digits of his or her Social Security Number or check the “I don’t have a Social Security Number” box below. (See Privacy Act
Statement on next page). Failure to complete this section, if income is listed, will result in the denial of free or reduced eligibility
*This application Is a revision of USDA’s newly released meal benefit prototype and meets all legal requirements and reflect design best practices
identified by USDA through focus testing and other research
Total income: Per: ☐ Week ☐ Every 2 Weeks ☐ Twice a month ☐ Monthly ☐ Yearly ☐ Household Size:
Categorical Eligibility: check ( ☐ ) if applicable Eligibility: check ONE ( ☐): Free ☐ Reduced ☐ Paid
Day Care Homes Only: check ( ☐) ONE ☐ Tier I ☐ Tier II
When more than one person is performing CACFP duties, there must be at least two signatures on this form: one signature from the
Determining Official (the official who determined initial income classification) and one signature from the Confirming Official (the
official who verified the form’s accuracy).
Determining Official’s Signature: Date
Confirming Official’s Signature: Date
Follow Up Official’s Signature: Date
We welcome you and your child to our classroom community! We are eager to know you and your child
better in the coming weeks. Please help us get started by sharing with us some important things about
your child. We encourage you to talk with us at any time and to provide all information that may help us to
teach and care for your child in a more complete way. We look forward to working together as partners in
support of your child.