Contact Us
    Skidaddles, Inc.
     8660 Bankers Street
     Florence, KY 41042
     Phone: (859) 647-PLAY (7529)
     Fax: (859) 647-7531
     info@skidaddles.com

Register

Registration is quick and easy! Simply submit the info below and we will have you set up and ready to go when you need us! Your ONE-TIME registration payment of $40 can be made at your first visit. Immunization Records will be due within 7 days of registration.
If you prefer, print out the form, fill it in and bring it in to us.

We are conveniently located on the corner of Houston Road and Highway 18 in the same building as Miyoshi Japanese Restaurant. Stop in for a tour anytime!

Register

Parent/Guardian Information:

Enrolling Parent/Guardian Name* :		Email :

Relationship to Child :		Driver’s License :

Address :		City :

State :		Zip :

Home Phone :		Cell Phone :

Work Phone :		Employer :



Parent /Guardian Name* :		Email :

Relationship to Child :		Driver’s License :

Address :		City :

State :		Zip :

Home Phone :		Cell Phone :

Work Phone :		Employer :

Child’s Information:

Name of each child (Last if Different)	Birth Date	Sex Circle One	Allergies











Please explain any additional information concerning your child’s allergies:
What school district does or will your child(ren) attend?

Emergency Contact Information:

In the event of an emergency and I am unable to be reached, I authorize the following persons to pick up my children:

Name :		Relationship :

Home Phone :		Cell Phone :


Name :		Relationship :

Home Phone		Cell Phone
Name		Relationship :
Home Phone :		Cell Phone :

Name of Physician :		Phone :

Hospital Preference :

Consent for Medical Treatment:

I give consent for Skidaddles to secure any and all necessary medical care for my child.


Please Print Full Name :

Signature :		Date :


Please Print Full Name :

Signature :		Date :

How did you hear about Skidaddles Drop –In Anytime Kid Care?

Who? We give gifts for referrals! :
Explain :

By checking this box, you are agreeing with our Policies and Prodedures

Register

Parent/Guardian Information:

Child’s Information:

Name of each child (Last if Different)

Birth Date

Sex Circle One

Allergies

Emergency Contact Information:

Consent for Medical Treatment:

How did you hear about Skidaddles Drop –In Anytime Kid Care?

Name of each child
(Last if Different)

Sex
Circle One