Expressive Imagination Academy, LLC 1901 South 12th Street, Bldg. 1, Suite 8, Allentown, PA 18103 Ph: 610-841-9997 Fax: 610-841-9697
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Expressive Imagination
Academy
Enrollment Packet
REVISED 04/2016
Expressive Imagination Academy, LLC 1901 South 12th Street, Bldg. 1, Suite 8, Allentown, PA 18103 Ph: 610-841-9997 Fax: 610-841-9697
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Registration Information
Registration Date:
Child Information
First Name: M.I. Last Name:
Name child prefers to be called: Grade/Class:
Child’s Address:
Gender: [ ] Male [ ] Female Date of Birth: ______________
Photographs: May we take and maintain a photo of your child for security purposes? [ ] Yes [ ] No
Parent/Guardian Information
Mother/Guardian First Name: M.I. Last Name:
Address:
Occupation: Home Phone: ( )
Employed By: Office Phone: ( )
Work Address: Work Hours: Cell Phone: ( )
[ ] Custodial Parent (If married, mark both parents) Email:
Driver’s License #:
Marital Status: [ ] Married [ ] Single [ ] Divorced [ ] Separated [ ] Widowed
[ ] Other_____________________
Father/Guardian First Name: M.I. Last Name:
Address:
Occupation: Home Phone: ( )
Employed By: Office Phone: ( )
Work Address: Work Hours: Cell Phone: ( )
[ ] Custodial Parent (If married, mark both parents) Email:
Driver’s License #:
__ __
Marital Status: [ ] Married [ ] Single [ ] Divorced [ ] Separated [ ] Widowed
[ ] Other_____________________
Expressive Imagination Academy, LLC 1901 South 12th Street, Bldg. 1, Suite 8, Allentown, PA 18103 Ph: 610-841-9997 Fax: 610-841-9697
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Emergency Contacts & Authorized Pickup Persons:
1st Contact/Pick Up
Name: ___________________________________________
Phone: ________________
Relationship to the Child: __________________________
2nd Contact/Pick Up
Name: ___________________________________________
Phone: ________________
Relationship to the Child: __________________________
3rd Contact/Pick Up
Name: ___________________________________________
Phone: ________________
Relationship to the Child: __________________________
4th Contact/Pick Up
Name: ___________________________________________
Phone: ________________
Relationship to the Child: __________________________
Expressive Imagination Academy, LLC 1901 South 12th Street, Bldg. 1, Suite 8, Allentown, PA 18103 Ph: 610-841-9997 Fax: 610-841-9697
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Medical Information
Physician / Health Care Provider Name:
Phone: ( )
Address:
Insurance Provider (Required):
Policy Number (Required):
List any existing medical conditions, medication your child may require:
1.) __________________________________________________________________________
2.)
3.)
4.) __________________________________________________________________________
**ALL MEDICATIONS MUST BE GIVEN WITH PRESCRIBED LABELS FROM HEALTH CARE PROVIDER, WITH
SPECIFIC WRITTEN CONSENT FOR TIME AND ADMINISTRATION.
Allergies (Including Food/Medication):
Special Disabilities (if any): ____________________________________________________
_____________________________________________________________________________
Medical or Dietary Information in an Emergency Situation: _________________________
_____________________________________________________________________________
Additional Special Needs Information: ___________________________________________
_____________________________________________________________________________
Expressive Imagination Academy, LLC 1901 South 12th Street, Bldg. 1, Suite 8, Allentown, PA 18103 Ph: 610-841-9997 Fax: 610-841-9697
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Parental Permissions
Parent’s Signature is Required for Each Item Below to Indicate Parental Consent
Obtaining Emergency Medical Care: ______________________________________________
Admin of Minor First Aid Procedures: _____________________________________________
Walks and Trips: ______________________________________________________________
Swimming: __________________________________________________________________
Transportation by Facility: ______________________________________________________
Wading: _____________________________________________________________________
Permission to Photograph Child I give Expressive Imagination Academy, LLC, permission to photograph my child/children
for the following purposes:
* Still Photographs
* Display in facilities scrapbook or bulletin boards shown to current or prospective
clients
** Display still photos on my daycare website
** Only first names and possibly last initials (In the event of two or more children with
the same first name) will be displayed on the facility website.
I understand that it is my responsibility to update this form in the event that I no longer wish
to authorize one or more of the above uses. I agree that this form will remain in effect during
the term of my child’s enrollment.
____________________________________ ____________________________________
Parent/Guardian Signature Date
I am declining to have my child photographed.
____________________________________ ____________________________________
Parent/Guardian Signature Date
Expressive Imagination Academy, LLC 1901 South 12th Street, Bldg. 1, Suite 8, Allentown, PA 18103 Ph: 610-841-9997 Fax: 610-841-9697
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PAYMENT AGREEMENT
Child Name: ____________________________________________
Tuition Payment Amount: $__________ Arrival time: _____ Pick-Up time: _____
All Payments are due on Monday (or your child’s first day of care) in full.
Please circle one: Part-Time Full-Time Before / After Care Full-time: Childcare that is provided 25 hours or more per week
Part-time: Childcare that is provided less than 25 hours per week
Please circle the days required for child care:
MON TUES WED THURS FRI SAT SUN
*All meals (including formula/baby food) are provided by Expressive Imagination Academy.
**Two changes of clothing including undergarments must be bought in. Bedding should be brought in on the first
day of care each week and taken home at the end of the week. Blankets, sheets, and or sleeping bags must be
supplied by parent or guardian.
***For Infants and Young Toddlers, parents must supply diapers
Meal times are as follows:
Breakfast: 7:15am – 8:15am Lunch: 11:00am-12:00pm Dinner: 5:00pm-6:00pm
Allergies: __________________________ ___________________________
Person(s) Designated By Parent to Whom Child May be Released
1.)
2.)
3.)
4.)
____________________________________ ____________________________________
Parent/Guardian Signature Date
____________________________________ ____________________________________
Director / Owner Signature Date
Date of Admission Date of Withdrawal
Periodic Review
Parent / Guardian Signature: Date:
Expressive Imagination Academy, LLC 1901 South 12th Street, Bldg. 1, Suite 8, Allentown, PA 18103 Ph: 610-841-9997 Fax: 610-841-9697
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FEES / POLICIES Late Fee’s
There is a ten hour maximum (per day) that your child may be left in care. There is a fee of
$15.00 for every half-hour (30 minutes) a child is picked up after their indicated pick-up time.
Any accrued late fees will be added to your payment the following week.
All emergency contacts are listed on Emergency Consent form. I agree to keep their names
and numbers as well as my own updated as needed.
Sick care:
Children are not to be brought or left in care with the following symptoms:
Excessive Runny Noses Excessive coughing Diarrhea Sneezing Temperature 101+
(Other illness/symptoms are listed in Parent Handbook)
As this is contagious and a sign of infection, your child must remain out of care a full 24 hours
and will require a written note from a licensed health care professional stating that the child is
not contagious in order to return. Expressive Imagination Academy does not have the ability
to take care of sick children along with other children who are non-symptomatic. Therefore,
please do not bring your ill child as you will be called and required to pick them up.
Children on medication must bring instructions from the doctor, or a form will be provided to
the parent to list permission, dosage, and times medicine is to be administered. Immunization
records and the date of your child’s last physical examination must be kept up to date. Parents
are required to review and update the records for accuracy at least once in a six month period.
Please notify us of any health problems or concerns regarding your child or family.
[ ] I have received a copy of the Expressive Imagination Academy Parent Handbook
____________________________________ ____________________________________
Parent/Guardian Signature Date
____________________________________ ____________________________________
Director / Owner Signature Date
Expressive Imagination Academy, LLC 1901 South 12th Street, Bldg. 1, Suite 8, Allentown, PA 18103 Ph: 610-841-9997 Fax: 610-841-9697
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“Getting To Know You”
Child’s Name: ___________________________________________
Name of Meeting Attendees: _____________________________________________________
Meeting Dates: Enrollment: ______________ Getting To Know You: _______________
If “Getting To Know You” meeting was refused...
Date of refusal by parent: _____________ Parent Initials: _________
1. Who lives in the household with your child: (Please list names, relationship & age)
_____________________________________________________________________________
_____________________________________________________________________________
2. Does your child have any parent that does not live in the home? Yes ___ No ___
Does your child visit this parent? Yes ____ No ____ Are there any custody issues we should
discuss? Yes ____ No ____
_____________________________________________________________________________
_____________________________________________________________________________
3. Does your child respond to nicknames? __________________________________________
4. Is there any information about your family that you would like to share?
_____________________________________________________________________________
_____________________________________________________________________________
5. Has your child been in an early learning program or child care before? If yes please answer
the following:
Where: __________________________________ When: ____________________________
How Long: ___________ Reason for leaving: _______________________________________
Expressive Imagination Academy, LLC 1901 South 12th Street, Bldg. 1, Suite 8, Allentown, PA 18103 Ph: 610-841-9997 Fax: 610-841-9697
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6. What are your child’s favorite foods? ____________________________________________
_____________________________________________________________________________
7. What are your child’s least favorite foods? _______________________________________
_____________________________________________________________________________
8. What (how do you) calms your child down? ______________________________________
_____________________________________________________________________________
9. What angers your child? ______________________________________________________
_____________________________________________________________________________
10. Are there any special problems or fears we should know about? _____________________
_____________________________________________________________________________
11. Does your child have any special needs / medical, developmental, social or mental health?
Yes ___ No ____ Do any of these special needs require special care by our teachers/staff?
_____________________________________________________________________________
_____________________________________________________________________________
12. Is your child potty trained? Yes ____ No ____ Would you like our assistance? Yes ____
No ____
13. Is there any information that will help us make the first few days in our program easier for
your child?
_____________________________________________________________________________
_____________________________________________________________________________
Expressive Imagination Academy, LLC 1901 South 12th Street, Bldg. 1, Suite 8, Allentown, PA 18103 Ph: 610-841-9997 Fax: 610-841-9697
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Stakeholders List / Parent Input
1. What school district will your child be attending in the future?
____________________________________________________________________
____________________________________________________________________
2. Please write the appropriate Elementary/ Middle School your child attends or will be
attending.
____________________________________________________________________
____________________________________________________________________
3. Please share any other possible partner of human service agency that would be
responsible for the success of the transition to kindergarten for your child.
____________________________________________________________________
____________________________________________________________________
Expressive Imagination Academy, LLC 1901 South 12th Street, Bldg. 1, Suite 8, Allentown, PA 18103 Ph: 610-841-9997 Fax: 610-841-9697
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IEP / IFSP
The status of your child’s growth and development is based on developmental assessments. If
your child currently has an IEP / IFSP it would be beneficial if you would share a copy of this
plan with us, so that we can work together to ensure the guidelines are practiced.
1. Does your child have an IEP: Individualized Education Plan or IFSP Individualized
Family Service Plan? Yes ____ No ____
If so, we would like a copy of the plan so that we can provide the best possible learning
experience for your child.
2. What program or individuals work with your child in regards to these special needs?
Would you sign a release of information with them so they can speak with us about how
to provide enhanced support for your child?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
[ ] My child does not have an IEP / IFSP
____________________________________ ____________________________________
Parent/Guardian Signature Date
[ ] My child has an IEP / IFSP plan, which I have provided to EIA
____________________________________ ____________________________________
Parent/Guardian Signature Date
[ ] My child has an IEP / IFSP that I choose not to provide at this time.
____________________________________ ____________________________________
Parent/Guardian Signature Date
CHILD HEALTH REPORT (55 PA CODE §§3270.131, 3280.131 AND 3290.131)
Par
ent/P
rovi
der
fill i
n th
is p
art. CHILD’S NAME: (LAST) (FIRST) PARENT/GUARDIAN:
DATE OF BIRTH: HOME PHONE: ADDRESS:
CHILD CARE FACILITY NAME:
FACILITY PHONE: COUNTY: WORK PHONE:
� I authorize the child care staff and my child’s health professional to communicate directly if needed to clarify information on this form about my child.
PARENT’S SIGNATURE:
Par
ents
may
wri
te im
mun
izat
ion
date
s; h
ealth
pro
fess
iona
l sho
uld
veri
fy a
nd c
ompl
ete
all d
ata.
DO NOT OMIT ANY INFORMATION This form may be updated by a health professional. Initial and date any new data. The child care facility needs a copy of the form.
HEALTH HISTORY AND MEDICAL INFORMATION PERTINENT TO ROUTINE CHILD CARE AND DIAGNOSIS/TREATMENT IN EMERGENCY (DESCRIBE, IF ANY): � NONE
DESCRIBE ALL MEDICATION AND ANY SPECIAL DIET THE CHILD RECEIVES AND THE REASON FOR MEDICATION AND SPECIAL DIET. ALL MEDICATIONS A CHILD RECEIVES SHOULD BE DOCUMENTED IN THE EVENT THE CHILD REQUIRES EMERGENCY MEDICAL CARE. ATTACH ADDITIONAL SHEETS IF NECESSARY. � NONE
CHILD’S ALLERGIES (DESCRIBE, IF ANY): � NONE
LIST ANY HEALTH PROBLEMS OR SPECIAL NEEDS AND RECOMMENDED TREATMENT/SERVICES. ATTACH ADDITIONAL SHEETS IF NECESSARY TO DESCRIBE THE PLAN FOR CARE THAT SHOULD BE FOLLOWED FOR THE CHILD, INCLUDING INDICATION OF SPECIAL TRAINING REQUIRED FOR STAFF, EQUIPMENT AND PROVISION FOR EMERGENCIES. � NONE
IN YOUR ASSESSMENT, IS THE CHILD ABLE TO PARTICIPATE IN CHILD CARE AND DOES THE CHILD APPEAR TO BE FREE FROM CONTAGIOUS OR COMMUNICABLE DISEASES? � YES � NO IF NO, PLEASE EXPLAIN YOUR ANSWER:
HAS THE CHILD RECEIVED ALL AGE APPROPRIATE SCREENINGS LISTED IN THE ROUTINE PREVENTIVE HEALTH CARE SERVICES CURRENTLY RECOMMENDED BY THE AMERICAN ACADEMY OF PEDIATRICS? (SEE SCHEDULE AT WWW.AAP.ORG)
� YES � NO
NOTE BELOW IF THE RESULTS OF VISION, HEARING OR LEAD SCREENINGS WERE ABNORMAL. IF THE SCREENING WAS ABNORMAL, PROVIDE THE DATE THE SCREENING WAS COMPLETED AND INFORMATION ABOUT REFERRALS, IMPLICATIONS OR ACTIONS RECOMMENDED FOR THE CHILD CARE FACILITY.
VISION (subjective until age 3)
HEARING (subjective until age 4)
LEAD
RECORD DATES OF IMMUNIZATIONS BELOW OR ATTACH A PHOTOCOPY OF THE CHILD’S IMMUNIZATION RECORD
IMMUNIZATIONS DATE DATE DATE DATE DATE COMMENTS
HEP-B
ROTAVIRUS
DTAP/DTP/TD
HIB
PNEUMOCOCCAL
POLIO
INFLUENZA
MMR
VARICELLA
HEP-A
MENINGOCOCCAL
OTHER
MEDICAL CARE PROVIDER:
ADDRESS:
PHONE:
SIGNATURE OF PHYSICIAN, CRNP OR PHYSICIAN’S ASSISTANT
TITLE:
LICENSE NUMBER: DATE FORM SIGNED:
CD 51 09/08
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