11 Park Lake Road
Sparta, NJ 07871
Phone: 973-383-2213
Fax: 973-383-5915

LilKeepers Registration


2017 - 2018 School Year *All fields of information on this form are required to be filled in before submission.*

School Name *

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Date of Application: *

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Date of Birth *
/ /
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Start Date: *

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Child's Name: *

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Child's Gender: *

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Street: *

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City: *

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Zip Code: *

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Phone Number (i.e., 1234567890): *

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Your Preferred Email Address: *

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Secondary Email Address

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Mother's Information

Relationship to Child *

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Mother's Name *

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Home Number (i.e., 1234567890): *

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Cell Number (i.e., 1234567890): *

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Home Address(complete): *

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Employer's Name: *

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Employer's Address: *

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Employer's Phone (i.e., 1234567890): *

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Work Email Address: *

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Father's Information

Relationship to Child *

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Father's Name *

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Home Number (i.e., 1234567890): *

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Cell Number (i.e., 1234567890): *

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Home Address(complete): *

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Employer's Name: *

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Employer's Address: *

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Employer's Phone (i.e., 1234567890): *

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Work Email Address: *

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Are you or your spouse currently enlisted in the Armed Forces? *

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Emergency Contacts: Persons authorized to pick up child in case of emergency if neither parent is available Please provide at least two LOCAL contacts. (persons must be at least 18 years of age)

Contact 1 *

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Relationship: *

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Address: *

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Phone Number (i.e., 1234567890): *

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Cell Number (i.e., 1234567890): *

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Contact 2 *

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Relationship: *

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Address: *

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Phone Number (i.e., 1234567890): *

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Cell Number (i.e., 1234567890): *

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Contact 3

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Relationship:

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Address:

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Phone Number (i.e., 1234567890):

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Cell Number (i.e., 1234567890):

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Contact 4

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Relationship:

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Phone Number (i.e., 1234567890):

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Cell Number (i.e., 1234567890):

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Contact 5

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Relationship:

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Address:

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Phone Number (i.e., 1234567890):

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Cell Number (i.e., 1234567890):

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Medical History

Date of last Tetanus Shot *

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Does the child have allergies? *

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Allergy List

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Is the child on medications? *

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Medication List

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Does the child have special needs? *

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Special Needs List

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Physician Name *

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Physician Address (complete) *

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Physician Phone Number (i.e., 1234567890): *

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Additional Comments

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Photo Release *

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Enrollment Selection (check off days if you enroll in 2, 3 or 4 day programs)

5 days / Wk

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4 days / Wk

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3 days / Wk

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2 days / Wk

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Flex Program

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Note: Two FLEX days will be charged when used on early or half day dismissal


Financial Assistance - K.E.E.P., Inc. has a variety of resources from which we can offer scholarship and financial assistance to those in need.

I am in need of financial assistance.

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If YES, someone from the K.E.E.P., Inc. Administrative Offices will contact you.


Releases and Signatures


I give my permission for my child to remain in the care of the K.E.E.P. Supervisor designated by the K.E.E.P., Inc. administration. He/she is in good physical health, has had the necessary immunizations for his/her age and to the best of my knowledge is free of any contagious diseases. I agree to abide by Project K.E.E.P.'s rules, which I have read, understand and accept. In the event that a medical emergency occurs, I authorize K.E.E.P., Inc. and its affiliate staff to seek emergency care for my child as deemed necessary the the Director. I agree that in the event of serious injury, my child will be transported to the nearest area hospital by the emergency squad. K.E.E.P., Inc. its Administration and/or Staff will not be held liable for any medical expenses incurred. (or foster K.E.E.P., Inc Supervisors do not dispense any medication.

Agreement Of Contract Terms *

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K.E.E.P. Financial Contract

I understand that all payments are due by the close of business (4:30 pm) on the 20th of each month preceding service. If payment in full is not made by the 20th of the month, regardless of the day of the week, a $25 Late Payment Fee will be added to your account. Any account balance not paid in full by this time will be charged to the credit/debit card provided in the financial contract. Should the credit/debit card be declined, services will be terminated the last day of the month until all charges are paid in full. In order for services to be reinstated, account balances must be paid in full, including a $50 Reinstatement Fee. A credit/debit card number MUST be provided by all clients for default purposes as outlined in this financial contract.

K.E.E.P., Inc. Invoices by Email. Your account can easily and securely be paid by clicking on the unique link on the bottom left of the invoice. Forms of payment accepted online are check, credit and debit card. Payments may also be made by cash, check, credit/debit card or money order in the Business Office. If payment is made by credit/debit card in the Business Office, a 2% Surcharge will be added to the total invoice amount.

The credit/debit card information below is to be used for default purposes (which may include but are not limited to: tuition, late payment fees, late pick up fees, K.E.E.P. supplied lunch, etc.) and will be kept secure and not shared with the public or any other agency. This section MUST be completed by all clients.

By completing this form, you authorize K.E.E.P. Inc. to deliver future invoices to you via e-mail to the address provided below. This address must match the e-mail address currently on file. To update the e-mail address on file, please call 973-383-2213. Sending an e-mail to your e-mail address on record, with no bounce-back, is conclusive proof of simultaneous actual receipt by you.



Credit Card *

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Card Number *

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3 or 4 Digit Verification Code on back *

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Expiration Date *

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Billing Address for Card:

Street: *

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City: *

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State: *

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Zip Code: *

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Signature(s) Of Person(s) Responsible for Payment:

Signature *

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Date: *

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Signature *

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Date: *

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I understand that a non-refundable security deposit will be applied to the last month of service, if notification is received in writing by the 15th of the month prior to the last month of service and my account is current. Application of my deposit does not relieve me of the balance of the monthly charge. (EXAMPLE: written notification would be required by October 15th for a November 30th withdrawal or security deposit is forfeited.)

Initial Here *

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PLEASE READ THE FOLLOWING STATEMENT BEFORE PLACING SIGNATURE BELOW:

I have read, understand, agree to and accept all of the terms under which I have enrolled in K.E.E.P., Inc., incuding but not limited to the following:

a. K.E.E.P., Inc Handbook
b. K.E.E.P., Inc. Financial Policies as stated in the Handbook
c. Emergency Medical Care
d. Information to Parents Statement & Policy on Release of Children
e. Policy on Management of Communicable Diseases
f. K.E.E.P., Inc. Expulsion Policy
g. Photo release as indicated.

and all other provisions of this program as set forth by K.E.E.P., Inc. I have the right to cancel this contract within 72 hours of the date it is signed, providing the program has not been utilized.

Agreeing to and signing this electronic document is equivalent to signing a printed form and carries with it all responsibilities/penalties as such.

Signature *

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Date: *

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Submit Verification Code *
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