Enrollment Agreement

Completion of this agreement is required for enrollment. This form will enable us to better understand your child and meet his/her needs. Much of the information requested is necessary to comply with state childcare licensing regulations.

Enrollment Information

Child’s Information

Child’s name(Required)

First Middle Last Nickname

Age(Required)

Sex(Required)

Date of Birth(Required)

Parent/guardian/sponsor primary language(Required)

Address(Required)

Street Address City State ZIP Code

Child Living Arrangements(Required)

Mother

Father

Both Parents

Other

Family Information

List family members & pets your child lives with – include first names, relation and ages of siblings

Parent/guardian/sponsor

Relationship to child

Home phone

Cell phone

Home address if different from above

Street Address City State ZIP Code

Home email

Work email

Work phone

Employer

Employer address

Street Address City State ZIP Code

Work hours

Other

parent/guardian/sponsor

Relationship to child

Home phone

Cell phone

Home address if different from above

Street Address City State ZIP Code

Home email

Work email

Work phone

Employer

Employer address

Street Address City State ZIP Code

Work hours

Child Emergency Contact and Release Information (do not include parents/guardians/sponsors)

Please notify the center if an Emergency Release Contact will pick up your child on a given day.
[For the safety of your child, we request that all authorized pick up persons with whom staff is not familiar provide a photo ID at the time of pickup.]

Person #1(Required)

Relationship to child(Required)

Home phone(Required)

Cell phone

Home address(Required)

Street Address City State ZIP Code

Home email(Required)

Work email

Work Phone

Employer

Employer address

Street Address City State ZIP Code

Work hours

Person #2

Relationship to child

Home phone

Cell phone

Home address

Street Address City State ZIP Code

Home email

Work email

Work Phone

Employer

Employer address

Street Address City State ZIP Code

Work hours

(Use back of form for additional pickups)

The persons designated in this section will be contacted by us if you cannot be reached in the event of a medical or other emergency. Our staff will only release your child to you or to those persons listed above. If you want a person who is not identified above to pick up your child, you must notify our staff in advance, in writing. Your child will not be released without prior authorization.

Parent initial

Staff initial

Date

Medical Information

Child’s name(Required)

Birth date(Required)

Height

Weight

Hair color

Eye color

Child’s Medical & Developmental History

1. Does your child have any special medical conditions?

Yes

Explain

Does your child have any special medical conditions?

2. Does your child have any chronic illnesses?(Required)

Yes

Explain

Does your child have any chronic illnesses?

3. Please list a brief history of your child’s serious injuries and hospitalizations.

4. Does your child have diabetes?(Required)

Yes

If yes, please attach care instructions from your physician.

Max. file size: 50 MB.

5. Does your child have asthma?(Required)

Yes

If yes, please attach care instructions from your physician.

Max. file size: 50 MB.

6. Will medication be administered regularly?(Required)

Yes

If yes, please attach care instructions from your physician.

Max. file size: 50 MB.

7. Does your child have any special dietary needs?(Required)

Yes

Explain

Does your child have any special dietary needs?

8. Is your child able to fully participate in all activities?(Required)

Yes

Explain

Is your child able to fully participate in all activities?

9. Does your child have any physical restrictions?(Required)

Yes

Explain

Does your child have any physical restrictions?

10. Does your child function at the level of other children in his/her age group?(Required)

Yes

Explain

Does your child function at the level of other children in his/her age group?

11. Is your child able to walk(Required)

Yes

12. Can your child communicate his/her needs?(Required)

Yes

13. Does your child need assistance at meal time?(Required)

Yes

Explain

Does your child need assistance at meal time?

14. Does your child rest during the day?(Required)

Yes

15. Is your child toilet trained?(Required)

Yes

16. Does your child use any special equipment, such as breathing machine, wheelchair, hearing aid, braces, glasses etc.?(Required)

Yes

Explain

Does your child use any special equipment, such as breathing machine, wheelchair, hearing aid, braces, glasses etc.?

17. Does your child require one-to-one care/supervision on a regular basis for a significant period of time?(Required)

Yes

Explain

Does your child require one-to-one care/supervision on a regular basis for a significant period of time?

18. Does your child require any accommodations or modifications to fully and equally enjoy and participate in a group care setting?(Required)

Yes

Explain

Does your child require any accommodations or modifications to fully and equally enjoy and participate in a group care setting?

Illness History(Required)

(please check all that apply)

Please attach care instructions from your physician for any of these illnesses.

Max. file size: 10 MB.

Disease History

(Please check all that apply and add the date)

Disease History

Chicken Pox (Varicella)

Date

Chicken Pox (Varicella)

Disease History

Measles Rubeola

Date

Measles Rubeola

Disease History

Rubella (German Measles)

Date

Rubella (German Measles)

Disease History

Mumps

Date

Mumps

Disease History

Scarlet Fever

Date

Scarlet Fever

Disease History

Bronchiolitis

Date

Bronchiolitis

Disease History

Pneumonia

Date

Pneumonia

Disease History

Pertussis (Whooping cough)

Date

Pertussis (Whooping cough)

Disease History

Tetanus

Date

Tetanus

Disease History

Diphtheria

Date

Diphtheria

Disease History

Botulism

Date

Botulism

Disease History

Haemophilus Influenza

Date

Haemophilus Influenza

Disease History

Meningococcal Infection

Date

Meningococcal Infection

Disease History

Rabies

Date

Rabies

Disease History

Bacterial Meningitis

Date

Bacterial Meningitis

Allergies (please list)

Medication Allergies

Reaction

Bee Stings Allergies

Reaction

Food Allergies

Reaction

Respiratory Allergies

Reaction

Other Allergies

Reaction

Are any of these allergies life-threatening?

Yes

Please attach care instructions from your physician for any life-threatening allergies.

Max. file size: 10 MB.

Miscellaneous Screenings and Tests

(Please check all that apply and add the date of last screening)

Miscellaneous Screenings and Tests

Vision

Date

Vision

Miscellaneous Screenings and Tests

Hearing

Date

Hearing

Miscellaneous Screenings and Tests

Speech

Date

Speech

Miscellaneous Screenings and Tests

Developmental

Date

Developmental

Miscellaneous Screenings and Tests

Aptitude

Date

Aptitude

Miscellaneous Screenings and Tests

Educational

Date

Educational

Miscellaneous Screenings and Tests

Tuberculosis (PPD)

Date

Tuberculosis (PPD)

Miscellaneous Screenings and Tests

Sickle Cell Anemia

Date

Sickle Cell Anemia

Miscellaneous Screenings and Tests

Other

Date

Other

To the best of my knowledge the information contained above is accurate.

Parent initial(Required)

Staff initial

Date(Required)

Medical Information (continued)

Child’s name

Birth date

Child’s Medical Care Provider

Primary physician’s name

Primary physician’s practice name

Phone

Physician’s practice address

Street Address City State ZIP Code

Preferred hospital/clinic for emergency care

City

State

Dentist’s name

Dentist’s practice name

Phone

Dentist’s practice address

Street Address City State ZIP Code

Child’s Insurance Provider

Child’s health insurance provider name

Policy number

Secondary health insurance provider name

Policy number

Child’s Immunization History

(Please attach a copy of your child’s immunization records)

Below is a list of immunizations that your child may have received. Immunizations in bold are required by our state. [Check with your state requirements. You may do this at http://www.immunize.org/states/ ]

Select any immunization below that is a requirement(Required)

Additional Medical Policies

Emergency Medical Authorization & Consent

Authorization to Dispense External Preparations

I give my permission to this center to apply(Required)

Sunscreen

Insect repellant

Baby wipes

Band-aids

Neosporin or similar ointment

Similar first aid spray

Non-prescription ointment (such as A&D, Desitin, Vaseline)

Baby Powder

I have/ do not have special instructions for the application process.(Required)

have

do not have

Please specify

Parent initial(Required)

Staff initial

Date(Required)

Rate Agreement and Contract

Child’s name(Required)

Birth date(Required)

Hours of Operation

Regular operating hours are M-F 6am-6p.m. except closings for various holidays, and inclement weather as described in the Parent Handbook. Please consult the current calendar for holidays. There is no reduction in tuition as a result of center closures. Child(ren) can not exceed 10 hours a day.

The procedure to notify families should severe weather or other conditions prevent the program from opening on time or at all will be announced via email, Facebook and the Remind 101 app. If it becomes necessary to close early, we will contact you or someone listed in the Emergency Contact and Release, and it will be your responsibility to arrange for your child’s early pick up.

Scheduled Attendance

The days and hours that I wish to contract for child care are as follows:

Day of week

Monday

Start time (AM/PM)

End time (AM/PM)

Comments

Tuesday

Start time (AM/PM)

End time (AM/PM)

Comments

Wednesday

Start time (AM/PM)

End time (AM/PM)

Comments

Thursday

Start time (AM/PM)

End time (AM/PM)

Comments

Friday

Start time (AM/PM)

End time (AM/PM)

Comments

I would prefer to make tuition payments on a _______ basis

Weekly

Bi-weekly

Monthly

Fee Policy

(to be completed by staff; reviewed and initialed by the parent/guardian/sponsor after completion)

Starting on

a fee of

is due

weekly

Weekly

Other Agreements

Private Employment Acknowledgement and Release

Parent initial

Staff initial

Date

Other Agreements (continued)

Child’s name

Birth date

Handbook Acknowledgement

Contract Approval

Primary Parent/Guardian/Sponsor Signature(Required)

Date(Required)

Center Staff Signature

Date

CAPTCHA

Enrollment Agreement