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KCA Kids Culinary Academy 2012-2013 
Registration Information

During the school year, registration and scheduling payments should be paid and given to the Head Instructor Chef Gailyn Gagliardi or sent to 104 Tealbriar St., Burgaw, NC 28425. 
Monthly schedules are due by the 15th of the month prior to attendance (If the 15th falls on a non-business day, paperwork will be accepted the next business day). 
If registering more than one child, each child needs his or her own paperwork filled out completely. 
Students must bring a lunch on half and full day, unless otherwise specified.

Scheduling Fees and Hours of Operation:  
P.M. Session: after school until 6 p.m. $75.00 per week
Half – Day Session (early dismissal) $10.00 extra
Mid-Winter/Spring Break 
Full Day $40.00 
Payment may be paid by check, money order or cash. 
Late Scheduling Fees: 
Late Scheduling Fee: $5 (for schedules turned in after the due date). Schedules will not be accepted after 2 business days from the 15th of the month due date. 
Schedule Issues: We do not accept schedule changes. We cannot exchange days or take days off schedules. Days added on to a schedule are accepted only with the leader’s approval. There is a $5 fee for additions to the schedules. 
Late Pick-up: Starting at 6:01 p.m. $15 for every 15 minutes will be strictly enforced. Time used will be calculated from cell phone clock. 
REFUNDS and CREDITS: 
THERE WILL BE NO REFUNDS OR CREDITS IF A CHILD IS ABSENT FOR ANY REASON. Should school be cancelled due to inclement weather or any other situation affecting the school day, a credit will be given. Credits due to inclement weather or the district canceling school must be used by the end of the current school year. All accounts are cleared at the end of the school year. 
Returned Checks: 
Please be aware that any returned checks will be assessed at $30 service fee per check. All returned check fees/amounts must be re-paid by certified check or money order. 
*All fees and dates of operation are subject to change 

 KCA Kids Culinary Academy 
(Children’s Activities in a Responsible Environment) 
Welcome to KCA Kids Culinary Academy after school program. This booklet is designed to acquaint you with our school year program and policies. 
KCA is a program offering a variety of culinary & creative activities with a focus on nutrition, fitness & FUN under adult supervision, for children enrolled in Burgaw Elementary. 
The program was created to provide working parents, in Burgaw Elementary, quality care for their children during the school year. 
We reserve the right to cancel the program should enrollment fall below what is needed to maintain the program. 

KCA offers students a variety of physical, recreational, and educational activities which will include experimenting with cooking and baking, visits from other resources to extend fun learning experiences to their day, students designing their own personal cookbook that will be completed at the end of the year as well as dedicated time for homework. 
KCA Goals 
1. To provide students with a safe, relaxed environment in a educational after school program. 
2. To provide a nurturing, supportive atmosphere. 
3. To offer a variety of activities and materials that promotes a child’s creativity, as well as social, emotional, physical and intellectual development. 
4. To provide positive guidance for each student in order to develop confidence and responsibility, as well as respect for each other. 
5. To offer visits from other resources to extend fun learning experiences. 
Daily Information 
Children often play outside; please send the appropriate clothing. Gym shoes are required for playing outside. 
Snacks are provided; we encourage you to send a snack for after school if your child has a special request or dietary needs.
We strongly discourage children from bringing toys (including electronic devices) from home. We cannot be responsible for lost, broken, or stolen items. 

Rules for Children 
In every situation in life we are guided by a certain set of rules. Likewise, in every educational setting we also have rules. A leader in an educational position is continually faced with decisions about rules and consequences that will insure a successful program. 
At KCA we have chosen a plan for the children that emphasizes the positive aspects of the rules listed below. With such a system, the guidelines are clearly defined and a sense of ambiguity does not exist. When a child knows what is expected of them, they have the opportunity to make an appropriate choice of behaviors. It is our intention that this system will contribute to the growth of your child’s self-control and their ability to choose the correct behavior. 
Below are the rules of the Kids Culinary Academy. 
Students will: 
Listen to and follow the directions of the Instructor
Walk whenever inside the home 
Keep hands, feet and other objects to themselves 
Always ask permission to leave 
Be kind and considerate to instructor and other students. 

Discipline Procedures 
KCA reserves the right to deny attendance to any child due to any continuous physical, emotional or behavioral problems. The methods the staff will use for conflict resolution are: setting clear limits, redirection and positive guidance. If a problem arises the following steps will be taken. 
The child’s parent will be notified of the problem. 

The parent(s) will be notified a second time in a written disciplinary note, if the behavior has not changed. At this time consequences of this behavior will be discussed. 

If negative behavior persists, the instructor will meet with the parent(s) to develop an appropriate behavior plan along with a proposed timeframe for implementation of the plan. The parent(s) will also be informed of the daily progress of the child. 

If all reasonable approaches are exhausted and the pattern of negative behavior continues and/or the child’s actions are a threat to the well being and safety of other children and staff, the child may be placed on suspension. Behaviors that warrant suspension including the following: physical violence, biting, persistent bullying and swearing, verbal harassment of peers or staff and unauthorized departure from the program grounds. 

Suspensions may be up to 3 days for the first offense. If there is another incident, the child could be suspended for 5 days and with the 3rd offense, the student may be expelled from the KCA program. 

School Closings 

We are closed if the District cancelled school for any reason. 
During the school year, conditions may make it necessary to close because of inclement weather. School district practice is not to close unless weather and road conditions are such that the possible hazards outweigh the educational values of the day’s instruction. 
Parents will be informed of school closings through radio and television announcements. All KCA programs will follow the school policy due to inclement weather or other emergency situations that may arise. Parents are advised to have an alternate plan worked out before such emergencies occur. * If we are able to accommodate your child- we will. 
Student drop off and Pick up 
Parents are responsible for seeing that the child is signed in at Burgaw Elementary to be picked up by the KCA transportation vehicle or as taking Bus #161 (Drop off address for KCA is 510 E. Fremont St. Burgaw, NC 28425). We do not allow walk-ins without a parent accompanying a child. Children must be picked up and signed out by 6:00 p.m. Please be ready to show picture I.D. which must be displayed by any adult that is authorized to pick up the child. 
If the child has not been picked up by 7:00 p.m., the usual late fee will continue to be in effect. In addition, the leader will contact the Burgaw Police Department after the 7:00 p.m. deadline. The police will make the decision to call Protective Services. Please be assured that the program leaders will make every attempt to call the parents or any authorized emergency contact person listed. The safety and well-being of the child is our main concern. We understand that circumstance beyond your control, (i.e. weather, traffic) result 
in the late pick up of your child. However, we do incur cost 
to supervise your child therefore must charge a late fee. 
Medications 
We do not administer prescription or non prescription medication without the proper district protocol. Children may not keep or administer any type of medication. Please contact KCA Instructor for procedure. 
Health Procedures 
Illness 
According to the Health Department, children must be kept home if they have any symptoms of illness. During the course of the day’s activities, caregivers will take note of any changes in the appearance or behavior of the children. The KCA Instructor will contact you about coming to pick up your child if any symptoms appear while he/she is in our care. 
Serious Accident or Injury 
The procedure for a serious accident or injury of a child while in our care is that the child receives immediate attention and the appropriate people are called. The order of contact for a serious injury is: 
1. Attend to the child 
2. Call 911 
3. Contact the parent 





KCA- Kids Culinary Academy Information 
Instructor/ Director: Chef Gailyn Gagliardi
910-547-0669
Gailyn@cafeliardi.com
Bio: www.cafeliardi.net 
510 E. Fremont St. Burgaw, NC 28425 

KCA Registration Form 2012-2013 
Please fill out completely. 
Program Admission Date: _______________________ 
Child’s First Name: _____________________________________ History of Allergies: yes_______ no_______ 
Child’s Last Name: _____________________________________ ___________________________________________________ 
Address: _____________________________________________ Medical information on file at school office: _______________ 
City: __________________________ Zip Code: ____________ Sibling Name: ___________________________Grade________ 
Child’s Current School: Sibling Name: __________________________Grade_________ 


Grade entering this fall: _____________________ 
Custody Information: 
Child lives with: 
Both parents (birth or adoptive) _____ 
Custody: Joint ___ Mother ___ Father ___ 
Other: ________________________ 
(Notarized court documents required) 
CHILD’S BIRTHDATE: _______________________________ 
MALE _________________ FEMALE _________________ 
Family Doctor:___________________ Phone # ____________ 
Address: _______________________________________________ 
Dentist: ________________________ Phone # ______________ 
Preferred Hospital: ______________________________________ Insurance Carrier:____________________ Date of Tetanus:_______ 
Parent Information: Policy #________________________________ 
Mother’s First Name: ___________________________________ Father’s First Name: ______________________________________ 
Last Name:_____________________________________________ Last Name:________________________________________________ 
Address: _______________________________________________ Address: ________________________________________________ 

City: _____________________ State: ______ Zip Code: _______ City: ______________________ State: ______ Zip Code: _______ 
Phone: Phone: 
Home: ( ) ________________________________________ Home: ( ) ___________________________________________ 
E mail: ( ) ________________________________________ E mail: ( ) ___________________________________________ 
Cell: ( ) ________________________________________ Cell: ( ) ___________________________________________ 
Work: ( ) ________________________________________ Work: ( ) ___________________________________________ 
Employer Name: ________________________________________ Employer Name: ____________________________________________ 
Employer Address: _______________________________________ Employer Address: _________________________________________ 
Work Hours: _____________________________________________ Work Hours: ______________________________________________ 
List the persons that should be contacted in an emergency and who are also authorized to transport the above child. 
Name Address Relationship Phone Number 
1.____________________________ _____________________________________ ___________________ ___________________ 
2.____________________________ _____________________________________ ___________________ ___________________ 
3.____________________________ _____________________________________ ___________________ ___________________ 
4.____________________________ _____________________________________ ____________________ ____________________ 
I give permission to Kids Culinary Academy to secure emergency medical and/or emergency surgical treatment for the named minor while in KCA. 
Parent Signature: ______________________________________________________ Date Signed: _______________________________  
Rev. 06/12 

Health Care Questions 
Is your child in good health? ______________ 
List any activities that should be restricted______________________________ 
_____________________________________ 
Are your child’s immunizations up to date? 
Yes_________ No_______ 
The immunization record or appropriate waiver is on file with the child’s school? 
Yes ________ No________ 
 Photos 
During the course of the school year, we will from time to time take pictures of the children participating in various activities. We are respectfully requesting your permission to use these photographs in our bi-annual brochures, flyers or possibly on our web site. 
____ I agree to supply my child with 
appropriate sunscreen. 
____ KCA has my permission to 
use photos of my child for brochures/ flyers/ web-site. 
____ Please do not use my child’s photo on any publication. 
____ My child may watch movies rated G___ and or PG___. 
*I have read and understand the scheduling and late fee policy. Please check: ______ 


Child Name: ________________________________ 

I have read and checked the appropriate questions regarding Health Care and Photos 
________ _ _____________________ 
Parent Signature Date 


Health Care Plan 
Hand Washing 
Hand washing Procedures 
The following procedures will be used for hand washing: 
Have a single service towel available. 
Turn on the water to a comfortable temperature between 60 degrees and 120 degrees. 
Moisten hands with water and apply soap. 
Rub hands together vigorously until a soapy lather appears and continue for at least 10 seconds. 
Rub areas between finder, around nail beds, under fingernails, and jewelry, and back of hand. 
Rinse hands under running water until free of soap and dirt. Leave water running while drying hands. 
Dry hands with a clean, disposable paper or single use cloth. Turn off tab with disposable paper or single service towel. 

Hands shall be washed with soap under running water. The following are not approved substitutes for soap and running water: 
Hand sanitizers 
Water basins 
Pre-moistened cleansing wipes 

Handling Bodily Fluids 
KCA will use precautions when handling bodily fluids as instructed in the blood borne pathogen training. Steps used will include: 
Instructor will put on gloves. 
Clean up bodily fluid/diaper. 
Wash area with soap and water, rinse, and sanitize area. 
Wash hands of child. 
Take off gloves and wash hands. 

Cleaning and Sanitizing 
The following steps are to be followed for cleaning and sanitizing: 
Wash area/surface with warm water and soap/detergent. 
Rinse area/surface with clean water. 
Submerge, wipe, or spray the article or surface with a sanitizing solution. 
Let area/surface air dry. 



Sanitizing Solution 
Water and non-scented chlorine bleach solution with a concentrate of 1 tablespoon of bleach to one gallon of water. 
Commercial sanitizers specified on the label to be safe for food contact surface and used according to the manufacturer’s directions. 

Controlling Infections 
See universal precautions above. 
Toys and equipment will be washed immediately if dirty, or on a daily basis or when dirty. 
Children who have any type of communicable disease/condition will be removed from care and may return to care only with a doctor’s note. 
Children who become ill will be moved away from the children until they are picked up. 

Rev.6/12 
KCA- Kids Culinary Academy Receipt 
Payment may be made by check, money order or cash. 

Please Print: 
Student Name: __________________________ School: ______________________ Grade: _______ 
Parent Name: _____________________________ 
Total amount due: $______________________ 
Check: #___________ 
Money Order: #______________
Cash_____________
---------------------------------------------------------------------------------------------------------------------------- 
Please complete bottom portion and keep for your records. 
Student Name: ______________________________ 
Amount paid: _____________ 
Check or Money Order:#______________