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A Child's World

Enrollment Packet

Enrollment Information

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 child care licensing regulations.
Child’s Information
Child’s Name*
Child’s first name Child’s middle name Child’s last name
Child’s nickname
Age*
Sex*
Child’s primary language*
Parent/guardian/sponsor primary language*
Child’s home address*
Street Address City State / Province / Region ZIP / Postal Code
Does your child attend school?*
- Yes
- No
School name*
Grade*
School phone*
School address*
Drop off time*
Pick up time*
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*
Work phone*
Home address*
Same as child's address

Street Address City State / Province / Region ZIP / Postal Code
Home email*
Work email*
Employer*
Employer address*
Work hours*
Other parent/guardian/sponsor
Relationship to child
Home phone
Cell phone
Work phone
Home address
Same as child's address

Street Address City State / Province / Region ZIP / Postal Code
Home email
Work email
Employer
Employer address
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 pick up.]
Person #1*
Relationship to child*
Home phone*
Cell phone*
Address*
Street Address City State / Province / Region ZIP / Postal Code
Employer*
Employer address*
Person #2*
Relationship to child*
Home phone*
Cell phone*
Address*
Street Address City State / Province / Region ZIP / Postal Code
Employer*
Employer address*
Person #3*
Relationship to child*
Home phone*
Cell phone*
Address*
Street Address City State / Province / Region ZIP / Postal Code
Employer*
Employer address*
Consent
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
Medical Information
Height*
Weight*
Hair color*
Eye color*
Child’s Medical & Developmental History
Does your child have any special medical conditions?*
- No
- Yes
Explain*
Does your child have any chronic illnesses?*
- No
- Yes
Explain*
Please list a brief history of your child’s serious injuries and hospitalizations.
Does your child have diabetes?*
- No
- Yes
Please attach care instructions from your physician
Drop files here or
Does your child have asthma?*
- No
- Yes
Please attach care instructions from your physician
Drop files here or
Will medication be administered regularly?*
- No
- Yes
Please attach care instructions from your physician
Drop files here or
Does your child have any special dietary needs?*
- No
- Yes
Explain*
Is your child able to fully participate in all activities?*
- No
- Yes
Explain*
Does your child have any physical restrictions?*
- No
- Yes
Explain*
Does your child function at the level of other children in his/her age group?*
- No
- Yes
Explain*
Is your child able to walk?*
- No
- Yes
Can your child communicate his/her needs?*
- No
- Yes
Does your child need assistance at meal time?*
- No
- Yes
Explain*
Is your child toilet trained?*
- No
- Yes
Does your child use any special equipment, such as breathing machine, wheelchair, hearing aid, braces, glasses etc.?*
- No
- Yes
Explain*
Does your child require one-to-one care/supervision on a regular basis for a significant period of time?*
- No
- Yes
Explain*
Does your child require any accommodations or modifications to fully and equally enjoy and participate in a group care setting?*
- No
- Yes
Explain*
Illness History (please check all that apply)
- Select All
- Vision problems
- Nosebleeds
- Seizures
- Hearing problems
- Skin rashes
- Mouth sores
- Constipation
- Sore throats
- Fainting
- Diarrhea
- Ear infections
- Persistent cough
- Asthma/breathing problems
- Urinary tract infections
- Other
Other
Please attach care instructions from your physician for any of these illnesses.
Drop files here or
Disease History (please check all that apply and add the date)
- Select All
- Chicken Pox (Varicella)
- Bronchiolitis
- Botulism
- Measles Rubeola
- Pneumonia
- Haemophilus Influenza
- Rubella (German Measles)
- Pertussis (Whooping cough)
- Meningococcal Infection
- Mumps
- Tetanus
- Rabies
- Scarlet Fever
- Diphtheria
- Bacterial Meningitis
Chicken Pox (Varicella) (Date)
Date Format: MM slash DD slash YYYY
Bronchiolitis (Date)
Date Format: MM slash DD slash YYYY
Botulism (Date)
Date Format: MM slash DD slash YYYY
Measles Rubeola (Date)
Date Format: MM slash DD slash YYYY
Pneumonia (Date)
Date Format: MM slash DD slash YYYY
Haemophilus Influenza (Date)
Date Format: MM slash DD slash YYYY
Rubella (German Measles) (Date)
Date Format: MM slash DD slash YYYY
Pertussis (Whooping cough) (Date)
Date Format: MM slash DD slash YYYY
Meningococcal Infection (Date)
Date Format: MM slash DD slash YYYY
Mumps (Date)
Date Format: MM slash DD slash YYYY
Tetanus (Date)
Date Format: MM slash DD slash YYYY
Rabies (Date)
Date Format: MM slash DD slash YYYY
Scarlet Fever (Date)
Date Format: MM slash DD slash YYYY
Diphtheria (Date)
Date Format: MM slash DD slash YYYY
Bacterial Meningitis (Date)
Date Format: MM slash DD slash YYYY
Allergies
Medication Allergies
Allergies Reaction
Food Allergies
Allergies Reaction
Bee Stings Allergies
Allergies Reaction
Respiratory Allergies
Allergies Reaction
Other Allergies
Allergies Reaction
Are any of these allergies life-threatening?*
- Yes
- No
Please attach care instructions from your physician for any life-threatening allergies.
Drop files here or
Miscellaneous Screenings and Tests (please check all that apply and add the date of last screening)
- Vision
- Developmental
- Tuberculosis (PPD)
- Hearing
- Aptitude
- Sickle Cell Anemia
- Speech
- Educational
- Other
Other
Vision (Date)
Date Format: MM slash DD slash YYYY
Developmental (Date)
Date Format: MM slash DD slash YYYY
Tuberculosis (PPD) (Date)
Date Format: MM slash DD slash YYYY
Hearing (Date)
Date Format: MM slash DD slash YYYY
Aptitude (Date)
Date Format: MM slash DD slash YYYY
Sickle Cell Anemia (Date)
Date Format: MM slash DD slash YYYY
Speech (Date)
Date Format: MM slash DD slash YYYY
Educational (Date)
Date Format: MM slash DD slash YYYY
Other (Date)
Date Format: MM slash DD slash YYYY
Check box beside the statement:
To the best of my knowledge the information contained above is accurate.
Parent initial
Child’s Medical Care Provider
Primary physician’s name*
Primary physician’s practice name*
Phone*
Physician’s practice address
Street Address City State / Province / Region ZIP / Postal Code
Preferred hospital/clinic for emergency care
Preferred hospital/clinic for emergency care address
Street Address City State / Province / Region ZIP / Postal Code
Dentist’s name*
Dentist’s practice name*
Phone*
Dentist’s practice address
Street Address City State / Province / Region ZIP / Postal 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)
Drop files here or
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/ Bold any immunization below that is a requirement.]
- Anthrax
- Influenza
- Pneumococcal disease
- Smallpox
- Diphtheria
- Lyme Disease
- Polio
- Tetanus
- Haemophilus Influenzae type b (Hib)
- Measles
- Rabies
- Tuberculosis
- Hepatitis A
- Meningococcal disease
- Rotavirus
- Typhoid Fever
- Hepatitis B
- Mumps
- Rubella
- Varicella (Chickenpox)
- Human Papillomavirus (HPV)
- Pertussis (Whooping Cough)
- Shingles (Herpes Zoster)
- Shingles (Herpes Zoster)
Additional Medical Policies
1. Prior to enrollment, I must provide the center with updated medical and immunization information for my child. This information is to be kept current and updated in accordance with state child care regulations.
2. I agree to provide information to the child care center about my child’s conditions, illnesses, allergies or other needs.
3. If my child becomes ill with a reportable contagious disease, I understand that he/she will not be able to return until I bring in a physician’s note stating that he/she is no longer contagious.
4. If my child becomes ill during his/her time at the child care center, the staff will contact me to pick up my child. I will arrange for pick up as soon as possible and no later than 2 hours after being contacted. If I cannot be reached, the staff will contact those listed in the Child Emergency Contact and Release.
Emergency Medical Authorization & Consent
In case of a medical emergency, the staff will attempt to contact me, those listed in the Child Emergency Contact and Release, and lastly my physician.
In case of a medical emergency, I agree that my child may receive first aid and/or CPR.
In case of a medical emergency, I permit the transportation of my child to a local hospital or other urgent care facility, if necessary by paramedics or other emergency personnel.
In case of a medical emergency, I will be responsible for the emergency medical expenses.
In case of an accidental ingestion of a poisonous substance, I consent to my child being treated as directed by the Poison Control Center.
I give my permission to this center to apply. Please check which products you will permit.
- sunscreen
- insect repellant to my child
I understand that I must supply my own sunscreen and/or insect repellant with a valid expiration date, and it will be labeled with my child’s name.
I
- have special instructions for the application process.
- do not have special instructions for the application process.
Parent initial
Rate Agreement and Contract
Hours of Operation
Regular operating hours are 6:00 am to 5:30 pm except closings for various holidays, and inclement weather as described in the Family Handbook. Please consult the current calendar for holidays. There is no reduction in tuition as a result of center closures. The procedure to notify families should severe weather or other conditions prevent the program from opening on time or at all will be announced on FOX 8 WGHP and via Brightwheel. 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:
Monday (Start time)

: HH

MM
Monday (End time)

: HH

MM
Tuesday (Start time)

: HH

MM
Tuesday (End time)

: HH

MM
Wednesday (Start time)

: HH

MM
Wednesday (End time)

: HH

MM
Thursday (Start time)

: HH

MM
Thursday (End time)

: HH

MM
Friday (Start time)

: HH

MM
Friday (End time)

: HH

MM
Fee Policy
Starting on
Date Format: MM slash DD slash YYYY
fee of $
I would prefer to make tuition payments on a
- weekly
- bi-weekly
- monthly
- basis
Tuition is due and payable by
- Every Monday for weekly payers.
- First business day of the month for DSS vouchers and scholarship parent fees or monthly private pay families
Tuition is not subject to discounts for holidays, emergency closures (i.e., weather or pandemic), or absence other than hospitalization, unless owner agrees to discount or credit for special circumstances.
I agree to pay the full tuition on Monday of each week or the 1st of the month for each month.
I agree to pay the full tuition fee even if my child is absent for one or more days.
A late fee of $20 iis due if tuition is not received on time.
A non-refundable registration fee of $40 iis due yearly.
A late pick up fee of $1 per minute per child (not to exceed $10 per child) is due if my child is not picked up before closing.
Accounts two weeks in arrears may result in immediate termination of service.
My child may have the opportunity to participate in a special program or field trip that may have an additional fee due before the day of the event. A specific permission slip may be required.
All returned checks or ACH transactions (automatic debits) will be charged a fee of $35 . Two or more returned checks or ACH transactions will result in my account being placed on “money order only” or cash status.
A 2-week written notice is required for any child being withdrawn from the program. Failure to provide notice in writing will result in an additional charge for two weeks for services and if not paid would go to collections or small claims court.
A receipt for income tax purposes will be provided upon request.
Other Agreements
Private Employment Acknowledgement and Release
Any arrangement/employment between me and staff of this center (i.e., babysitting), outside of the programs and services offered by this center, is an individual endeavor and private matter not connected to or sanctioned by this center. This center shall remain harmless from any such arrangement.
Initial
Media Release
Occasionally, photos will be taken of the children at the center for use within the center or on our website and/or newsletters. Please indicate that you authorize the use and reproduction of photographs of your child in conjunction with the program.
Initial
Walking Excursions
I give my permission for my child to participate in supervised walking excursions near and around the center.
Initial
Handbook Acknowledgement
I understand and agree that it is my responsibility to read and familiarize myself with policies and procedures outlined in the Family Handbook and agree to abide by them. I understand that it is my responsibility to go directly to management with any questions I may have regarding the policies and procedures and information contained in this Enrollment Agreement. Information contained in the Family Handbook may be subject to change.
Initial
Contract Approval
I certify that I have read, understand, and accept all of the terms and conditions described in this Enrollment Agreement.
Primary Parent/Guardian/Sponsor Signature
Date
Date Format: MM slash DD slash YYYY

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