ENROLLMENT APPLICATION 2012 · 5 Enrollment 2012 EMERGENCY RELEASE FORM (FILE COPY) Either a parent...
Transcript of ENROLLMENT APPLICATION 2012 · 5 Enrollment 2012 EMERGENCY RELEASE FORM (FILE COPY) Either a parent...
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Enrollment 2012
Misty M. Slater
10956 SW Bretton Ct
Tigard, OR 97224
Phone: 503.679.8539
Email: [email protected]
http://www.littlefeetchildcare.com
ENROLLMENT APPLICATION
2012 Child’s Name:
Date of Birth:
Address:
Phone:
GUARDIAN INFORMATION Guardian 1’s Name: Home Phone:
Address: Work Phone:
Cell Phone:
Employer:
Address:
Date of Birth:
Email:
Guardian 2’s Name: Home Phone:
Address: Work Phone:
Cell Phone:
Employer:
Address:
Date of Birth:
Email:
MEDICAL FORM
(FILE COPY)
Enrollment Status: Enrollment Date: Student ID: __________________
If there is a court order for guardianship, LFCC must have a copy of the court order on file at time of enrollment
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Child’s Name: DOB:
Mother’s Name: Phone:
Father’s Name: Phone:
Insured Name:
Insurance Carrier: Policy #:
Doctor’s Name: Phone:
Address:
Dentist Name: Phone:
Our child care provider, MISTY SLATER has our permission for the following:
(please check all that apply)
o to call an ambulance if necessary
o to take our child to a physician or hospital in case of emergency
o to give prescription medication when instructed as prescribed by child’s physician
o to give non-prescription medication as instructed by parents
o Tylenol
o Motrin
o Orajel
o Teething tablets
o Sunscreen (LFCC supplies Neutrogena Sunscreen)
o Other Sunscreen (you must supply it)
o Other (please specify)
I/We understand that any medical expenses necessary are my/our responsibility.
_________________________ ______________________
Signature Signature
_________________________ ______________________
Date Date
Immunization Record on File Y N
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MEDICAL FORM
(EMERGENCY COPY)
Child’s Name: DOB:
Guardian 1’s Name: Phone:
Guardian 2’s Name: Phone:
Insured Name: Policy #:
Insurance Carrier:
Doctor’s Name: Phone:
Address:
Dentist Name: Phone:
Our child care provider, MISTY SLATER has our permission for the following:
(please check all that apply)
o to call an ambulance if necessary
o to take our child to a physician or hospital in case of emergency
o to give prescription medication when instructed as prescribed by child’s physician
o to give non-prescription medication as instructed by parents
o Tylenol
o Motrin
o Orajel
o Teething tablets
o Sunscreen (LFCC supplies Neutrogena)
o Other Sunscreen (you must supply)
o Other (please specify)
I/We understand that any medical expenses necessary are my/our responsibility.
_________________________ ______________________
Signature Signature
_________________________ ______________________
Date Date
Immunization Record on File Y N
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EMERGENCY RELEASE FORM
(EMERGENCY COPY) Either a parent or a guardian, having legal custody of a minor, may give written authorization for an adult, into whose care the
minor has been entrusted, to consent to x-ray examinations, anesthesia, medical or surgical diagnosis and/or treatment and
hospital care to be rendered, to the said minor, under the provisions of the medical practice act, or to x-ray examinations,
anesthesia, dental and/or treatment and hospital care to be rendered to said minor by a dentist licensed under the dental
provisions law.
Child’s Name:
Child’s Doctor: Phone:
Child’s Dentist: Phone:
Insured Company: Policy #:
Guardian 1’s Name: Guardian 2’s Name:
Home Phone: Home Phone:
Work Phone: Work Phone:
Cell Phone: Cell Phone:
AUTHORIZATION I ___________ and/or ____________ understand the above and hereby authorize Misty M. Slater , owner of
Little Feet Child Care, LLC to give permission for any necessary medical, hospital or dental treatment for my child,
________ in the event of injury or illness while the child is in care of the above name provider or center. I understand
and agree that I would be financially responsible for any medical treatment necessary. I have full understanding that every
attempt will be made to contact the parent/guardian in the even that medical treatment is necessary. I understand that certain
medical emergencies may not allow much time for contact of the parent/guardian and that if a life threatening situation arises,
immediate attention will be sought by the provider.
______________________________ _________________________
Signature Signature
_______________________________ _________________________
Date Date
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Enrollment 2012
EMERGENCY RELEASE FORM
(FILE COPY) Either a parent or a guardian, having legal custody of a minor, may give written authorization for an adult, into whose care the
minor has been entrusted, to consent to x-ray examinations, anesthesia, medical or surgical diagnosis and/or treatment and
hospital care to be rendered, to the said minor, under the provisions of the medical practice act, or to x-ray examinations,
anesthesia, dental and/or treatment and hospital care to be rendered to said minor by a dentist licensed under the dental
provisions law.
Child’s Name:
Child’s Doctor: Phone:
Child’s Dentist: Phone:
Insured Company: Policy #:
Guardian 1’s Name: Guardian 2’s Name:
Home Phone: Home Phone:
Work Phone: Work Phone:
Cell Phone: Cell Phone:
AUTHORIZATION I ___________ and/or ____________ understand the above and hereby authorize Misty M. Slater , owner of
Little Feet Child Care, LLC to give permission for any necessary medical, hospital or dental treatment for my child,
________ in the event of injury or illness while the child is in care of the above name provider or center. I understand
and agree that I would be financially responsible for any medical treatment necessary. I have full understanding that every
attempt will be made to contact the parent/guardian in the even that medical treatment is necessary. I understand that certain
medical emergencies may not allow much time for contact of the parent/guardian and that if a life threatening situation arises,
immediate attention will be sought by the provider.
______________________________ _________________________
Signature Signature
______________________________ _________________________
Date Date
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HEALTH HISTORY
Child’s Name: Date of Birth:
Last Physical Exam:
**A COPY OF YOUR CHILD'S IMMUNIZATION RECORD FROM THE DOCTOR IS REQUIRED
FOR YOUR CHILD'S FILE**
Vaccination Dose 1 Dose 2 Dose 3 Dose 4 Dose 5
Diptheria/Tetanus
DTaP
2 months 4 months 6 months 18 months 5 years
Polio
IPV or OPPV
6 months 9 months 18 months 5 years
Chickenpox
Varicella
12 months Booster
Measles/Mumps/Rubella
MMR
12 months 5 years
Hepatitis B
Hep B
1 month 2 months 9 months
Haemophilus Influenza
Hib
2 months 4 months 6 months 15 months
Hepatitis A
Hep A
Pneumococcal
PCV7 (under 5)
2 months 4 months 6 months 18 months
Meningococcal
MCV7 (ages 11-18)
Tetanus/Diptheria
Booster
12-15 years
Other:
Other:
Other:
Other:
Allergies:
Dietary Restrictions
Has your child been hospitalized? (explain)
_____________________________________________________________
_____________________________________________________________
Has your child had injuries with fractures or loss of consciousness? (explain)
_____________________________________________________________
_____________________________________________________________
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PICK UP AUTHORIZATIONS
The following people listed below are allowed to pick up my/our child,
, if instructed by the parent/guardian.
Name: Phone:
Name: Phone:
Name: Phone:
Name: Phone:
Name: Phone:
Name: Phone:
Additional Comments:
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
IN CASE OF AN EMERGENCY In case of an emergency, please contact one of the following if the parent/guardian cannot be reached.
Name: Phone:
Name: Phone:
Name: Phone:
Name: Phone:
Name: Phone:
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PHOTOGRAPH RELEASE
I/We _______________________, give permission for Misty M. Slater or staff at Little Feet Child Care, LLC to
photograph my child, ____________________. For the following purposes: (CHECK THOSE THAT APPLY)
o Still Photographs
o Display in Provider’s Scrapbook
o Give Photo’s to current clients
o Display on bulletin boards, shown to prospective Client’s
o Use still photos in promotional materials
o Upload to dropshots & snapfish for parents to print
o Little Feet Child Care, LLC Website (children's names are not used on website)
o Little Feet Child Care, LLC Facebook Page (children's names are not used on Facebook)
WATER RELEASE
I/WE give permission__ I/WE do not give permission __ to Misty Slater and staff of Little Feet Child Care, LLC for
my/our child to participate in water play (touch tub) or swimming activities (sprinklers) NO POOLS!
________________ _____________________
Signature Signature
________________ _____________________
Date Date
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Enrollment 2012
TUITION CONTRACT
Child’s Name: Date of Birth:
I __________and/or ___________ are in agreement that, I/WE will pay $ per month for
child care days per week to Little Feet Child Care, LLC. Payment is due at the beginning of the month. Payment
is required in advance. I/We understand that if our payment is received by provider, past the agreed upon payment date, we will be charged as
follows: a late payment of $25.00 for each day the payment is late. In addition, I/WE understand and agree that an additional
fee of $2.00 per minute will be charged if child(ren) are not picked up as agreed on this contract.
DAYS OF THE WEEK HOURS OF THE DAY
o Monday 7:00-5:30
o Tuesday 7:00-5:30
o Wednesday 7:00-5:30
o Thursday 7:00-5:30
o Friday 7:00-5:30
Additional Terms: Late fees will not apply if there are poor road conditions such as snow, ice, freezing rain, etc. If these are
the conditions, please call to inform provider that you will be arriving late.
If provider should receive a check back, due to insufficient funds, there will be a fee of $35.00. Late payment and/or
insufficient funds may result in termination of your child’s enrollment.
Should I/WE decide to discontinue child care services, I/WE will give 30 days notice. If 30 day notice is not given in writing,
tuition will not be reimbursed for those days.
________________ ______________
Signature Signature
________________ _____________
Date Date
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Enrollment 2012
CHILD CARE CLOSURES CONTRACT
I/We understand that the following days are paid closure days for Little Feet Child Care, LLC and are
responsible for finding our own back child care if necessary.
2012 HOLIDAY AND VACATION CLOSURES
All Vacation Days And Holidays Are Paid
January 2012 No Closures February 2012 Monday, February 20th President’s Day March 2012 Mon-Fri, March 26th -30th Vacation April 2012 No Closures May 2012 Monday, May 28th Memorial Day June 2012 No Closures July 2012 Wednesday, July 4th Independence Day Mon-Fri, July 9th - 13th Vacation August 2012 Monday, August, 27th Vacation Friday, August 31st Vacation September 2012 Monday, September 3rd Labor Day Friday, September 21st Vacation October 2012 No Closures November 2012 T, F November 22nd - 23rd Thanksgiving December 2012 Mon-Fri, December 24th - 28th Vacation Monday, December 31st New Year's Eve January 2013 Tuesday, January 1st New Year's Day
_______________ _____________
Signature Signature
_______________ _____________
Date Date
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ADDENDUM 2
ANNUAL ENROLLMENT FEE
The $100.00 annual enrollment fee is due prior to your child’s first day and January 1st every year after. The
fee helps to cover state required registration, training and licensing. However, if you enroll in the fall, you
will not accrue another enrollment fee in January. Your next enrollment fee will not come due until the
following January. For multiple children, the fee is $100.00 for the 1st child and $50.00 for each additional
child.
Example: Child A is enrolled in September 2011 and a $100.00 fee is charged. January 2012 arrives and the
$100.00 enrollment is waived. The next enrollment fee is due January 2013.
Signature Signature
Date Date
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ADDENDUM 3
DISCIPLINARY GUIDELINES
Little Feet Child Care, LLC follows the following guidelines for and not limited to…
Biting
Hitting
Kicking
Inappropriate Language
Any behavior which endangers the child(ren), teacher or environment
1. IDENTIFY-the inappropriate behavior
2. DOCUMENT-behavior, time of incident, place, activity occurring, including staff and director signatures
3. INFORM-parent (verbally and written, requiring parent signature)
4. OBSERVE-the environment, schedule, child/child interaction, developmental stages, staff/child interaction
5. CONFERENCE-with parent(s), teacher and director
6. PLAN OF ACTION-developed with developmentally appropriate practices as a guideline, in conjunction with
parent(s) and facility input. Including responsibilities of each party, time frame and date of follow up with the
understanding that any inappropriate behavior can and will necessitate immediate response which could occur prior
to scheduled follow up conference
7. FOLLOW UP AND OBSERVATION-track either successful improvement or any continuation of the inappropriate
behavior
8. COMMUNICATE-with parent(s) concerning observation. Could require development of an additional action plan
and/or request for alternative care
If the inappropriate behavior persists and/or the behavior is demonstrated routinely, Little Feet Child Care, LLC reserves the
right to request that alternative care be provided which can include one or all of the following: removal from daycare on the
day of the incident, brief request of absence from daycare, or dis-enrollment.
_______________ _____________
Signature Signature
_______________ _____________
Date Date
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ADDENDUM 1
(YOUR COPY)
2012 HOLIDAY AND VACATION CLOSURES
All Vacation Days And Holidays Are Paid
January 2012 No Closures
February 2012 Monday, February 20th President’s Day
March 2012 Mon-Fri, March 26th -30th Vacation
April 2012 No Closures
May 2012 Monday, May 28th Memorial Day
June 2012 No Closures
July 2012 Wednesday, July 4th Independence Day
Mon-Fri, July 9th - 13th Vacation
August 2012 Monday, August, 27th Vacation
Friday, August 31st Vacation
September 2012 Monday, September 3rd Labor Day
Friday, September 21st Vacation
October 2012 No Closures
November 2012 T, F November 22nd - 23rd Thanksgiving
December 2012 Mon-Fri, December 24th - 28th Vacation
Monday, December 31st New Year's Eve
January 2013 Tuesday, January 1st New Year's Day