Enrollment Agreement Child Care License # CCCB School Age License # 06343

Size: px

Start display at page:

Download "Enrollment Agreement Child Care License # CCCB School Age License # 06343"

Rosemary Sherman
5 years ago
Views:

1 Enrollment Agreement Child Care License # CCCB School Age License # Start Date 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. Enrollment Information Child s Information Child s first name Birth Date Child s middle name Sex Child s last name Child s primary language Child s nickname Parent/guardian/sponsor primary language Child s home address Zip School Age Only Does, or will, your child attend school? School name Grade School phone Yes No School address Drop off time rd My child is allowed to walk (3 grade and older * ): Pick-up time To School from Child Care From School to Child Care My child is transported from school via: Bus #: My child is transported to school via: Parents are responsible for informing child care center in writing if your child(ren) will be participating in an after school activity: Family Information List family members & pets your child lives with include first names, relation and ages of siblings Parent/guardian Relationship to child Home address if different from above Home 2013, CCA Global Partners, Inc. Home phone Work Cell phone Zip Work phone 1

2 Family Information (continued) Employer Employer address Zip Work hours Other parent/guardian Relationship to child Home phone Cell phone Home address if different from above Zip Home Work Work phone Employer Employer address Zip Work hours Child Emergency Contact and Release Information (do not include parents/guardians) Person #1 Relationship to child Home phone Cell phone Home address Zip Home Work Work Phone Employer Employer address Zip Work hours Person #2 Relationship to child Home phone Cell phone Home address Zip Home Work Work Phone Employer Employer address Zip Work hours Person #3 Relationship to child Home phone Cell phone Home address Zip Home Work Work Phone Employer Employer address Zip Work hours 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.] 2013, CCA Global Partners, Inc. 2

3 Enrollment Agreement Child Care School Age License # CCCB License # Medical Information Child s name Birth date Child s Medical Care Provider Primary physician s name Primary physician s practice name Physician s practice address Phone Preferred hospital/clinic for emergency care Dentist s name Zip Dentist s practice name Dentist s practice address Phone Zip Child s Insurance Provider Child s health insurance provider name Policy number Secondary health insurance provider name Policy number 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. 2013, CCA Global Partners, Inc. 3

4 Enrollment Agreement Child Care School Age License # CCCB License # Rate Agreement and Contract Child s name Birth date Name of parent/guardian responsible for payment Hours of Operation Regular operating hours are CHILD CARE - Monday through Friday from 6:30 AM to 5:30 PM and SCHOOL AGE PROGRAMMING - Monday through Friday from 6:30 AM to 6:00 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 WMUR TV station and 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 CHILD CARE and KINDERGARTEN WRAP PROGRM Day of week Start Time End Time Comments After School Comments Monday Tuesday Wednesday Thursday Friday SCHOOL AGE PROGRAM Day of week Before School Monday Tuesday Wednesday Thursday Friday 2013, CCA Global Partners, Inc. 4

5 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. Tuition is due on upon receipt of the invoice. Tuition is not subject to discounts for holidays, emergency closures (i.e., weather), or absence other than hospitalization, contagious illness, or absence at the request of a doctor (a written doctor s note is required to receive credit). For families with 2 or more children in our programming a 10% discount will be applied to the rate of the child with the lowest tuition. I agree to pay the full tuition fee even if my child is absent for one or more days. A late fee of $ per week is due if tuition is not received on time. A non-refundable registration fee of $50.00 is due upon the initial registration of a child in Child Care or School Age Programming. A late pick-up fee of $1.00 per minute per child (not to exceed $30.00 per child) daily is due if my child is not picked up before closing. Persons designated in the Emergency Contact 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 as a parent/guardian or emergency contact to pick up your child, you must notify our staff in advance, in writing. Your child will not be released without prior authorization. Families receiving a scholarship from the of New Hampshire are responsible for paying the difference, if any, between the state s reimbursement and White Birch s rate. Typically, the family cost share is only a portion of the total owed. Accounts more than two weeks in arrears may result in immediate termination of service. Field trips may have an additional fee due before the day of the event. A specific permission slip may be required. All returned checks will result in a late fee $ Two or more returned checks will result in a cash in advance status. A receipt for income tax purposes is available upon request. School Age Program Only - When the Henniker Community School is closed for weather or other emergencies, there will be no School Age Programming. School Age Program Only - When the Henniker Community School has a delayed start, there is no Before School Program. School Age Program Only During school vacation weeks White Birch offers full-day programming, similar to Summer Camp, at a daily or weekly rate. Parents who would like their child to attend this programming must give two weeks advance notice of their child s planned daily or weekly attendance so that proper staffing and billing can be arranged. Parents have the option to not attend programming during school vacation weeks, and if that is the case, there will be no tuition for that time period. School Age Program Only - Parents are responsible for informing the School Age Program in writing if your child(ren) will be participating in an after-school activity. School Age Program Only The White Birch School Age Program is not liable for a child until he/she arrives at the program or after the child has left the program. 2013, CCA Global Partners, Inc. 5

6 Forms of Payment Payments may be made by Cash, Check, or Credit Card (MC, VISA, Discover, and American Express) Make Checks Payable to WBCC. If the last name on the check differs from the child s last name, please note that on the Memo line. Please place payments in the Payment Mailboxes located outside of the 3-year old and 4-year old classrooms, or bring your payment to the office Monday through Friday 9:00 am to 5:30 pm. Payments can be mailed to: WBCC, P.O. Box 2035, Henniker, NH Termination of the Agreement This agreement may be modified or terminated by White Birch Community Center at any time. A two-week notice is required from families to terminate enrollment from this program. If a child is removed sooner, the family will still be assessed tuition for those two weeks. Signatures By signing this agreement, all parties agree to the above outlined terms and policies, including financial responsibility for costs incurred for participation in all White Birch Programs Contract Approval I certify that I have read, understand, and accept all of the terms and conditions described in this Enrollment Agreement and the Family Handbook. Primary Parent/Guardian/Sponsor Signature Date Center Staff Signature Date 2013, CCA Global Partners, Inc. 6

7 Enrollment Agreement Child Care License # CCCB School Age License # 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 or sanctioned by this center. This center shall remain harmless from any such arrangement. 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 receive first aid and/or CPR. In case of 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 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. Sunscreen & Insect Repellent I give my permission to this center to apply Sunscreen and Insect Repellent to my child (please check what you will permit). I understand that I must supply my own sunscreen and/or insect repellent with a valid expiration date, and it will be labeled with my child s name. I have special instructions for the application process None Media Release Occasionally, photos will be taken of the children in our programs for use within the program or on promotional material such as our website. - We are sensitive to children s feelings and would never intentionally use a photo that might embarrass a child. - We will remove any photograph from our website that the parent/guardian asks us to remove. YES NO I give my permission for his/her photo, individual or in a group, to be used on White Birch Community Center s Website or other materials such as a brochure, press coverage, or publicity piece. YES NO I give permission for White Birch Community Center staff to use photographs of my child on the classroom s Facebook page. The child s name, age, and address will not be used. Parent Signature Date 2013, CCA Global Partners, Inc. 7

8 Walking Excursions I give my permission for my child to participate in supervised walking excursions near and around the center. White Birch will supply walking route prior to the excursion. 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. WBCC Date Parent/Guardian Date Parent/Guardian Date Note to Parent(s) or Guardian(s) The licensing authority for this program is the Bureau of Licensing and Certification, Child Care Licensing Unit. Child care programs are required to post a copy of the statement of findings and corrective action plan for the most recent visit in a location which is accessible to parents, and must maintain copies of the statement of findings and corrective action plan for the preceding visit and make them available for parents to review upon request. ments of findings and corrective action plans are also available on-line at or by calling the unit at ext or During licensing, monitoring, and complaint investigation visits to licensed programs the department shall speak with children regarding the care they receive at the program, if in judgment of the licensing coordinator the children s response would be valuable determining compliance with licensing rules. Licensing staff are experienced in working with children and trained to interview in a manner that is respectful and non-leading. However, if you do not want your child interviewed, or if you wish to be informed prior to your child being interviewed you must give the family child care provider, center director, site director or designee, and update annually, a signed dated statement indicating your preference. For more information about Child Care Licensing please visit our website at: I have read the above notice and I give consent for my child to be interviewed by Child Care Licensing. I have read the above notice and I DO NOT give consent for to be interviewed by Child Care Licensing. Parent or Guardian Signature Date 2013, CCA Global Partners, Inc. 8

New Morning Registration and Emergency Information

2018-2019 New Morning Registration and Emergency Information This form must be completed for each of your children who will be enrolled in the program and must be updated whenever information changes.