6610 US Hwy 277 South Abilene, Texas

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6610 US Hwy 277 South Abilene, Texas 79606 325-692-3948 www.

1 6610 US Hwy 277 South Abilene, Texas Director: Ashley Neyhart

2 Summer 2018 Schedules and Fees Daily School Hours: 8:30 am 3:00 pm Summer Registration Fee: $25 per child Must be paid to reserve spot Monday Thursday: 0 18 months: 19m 5th Grade: Two-day Schedule: 0 18 months: 19m 5th Grade: Multi-child Discount: Friday add-on or Friday Only: $100 / week $90 / week $55 / week $50 / week $5 / week per additional child $25 / week Monday Friday Office Hours 8:15 am 3:30 pm Summer Session Dates Summer Begin Date: Summer End Date:

Nap Mat Labeled With Name, Floor-Side, And Up-Side (Class 1 & up) Sippy / Drinking Cup or Bottle Change Of Clothes (Can Be Left In Bag) 4 Rolls of Paper Towels 2 Disinfecting Wipes [Clorox wipes or

3 Nap Mat Labeled With Name, Floor-Side, And Up-Side (Class 1 & up) Sippy / Drinking Cup or Bottle Change Of Clothes (Can Be Left In Bag) 4 Rolls of Paper Towels 2 Disinfecting Wipes [Clorox wipes or Lysol wipes] 1 Gallon of Bleach 1 Large Box of Snacks [pretzels, cheese cracker, veggie straws, crackers, etc.] 1 Box of Gallon Zip Lock Bags 1 Box of Baby Wipes 1 Package of Napkins OR You may pay a $25 Supply Fee ALL PERSONAL ITEMS MUST BE LABELED WITH YOUR CHILD S NAME A class-specific supply list may be requested by your child s teacher. 3

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5 Child s Name: Enrollment Packet Checklist Child-care Enrollment Agreement Completed Admission Information Statement of the child s health from a health-care professional Immunization Records Vision and hearing screening information, if applicable. o Required for age 4+ o Refer to Policy Manual for further information. Policy Manual can be found at Medication information and any notes from healthcare professional o Please see procedures for dispensing medication in Policy Manual. A copy of any health-care professional recommendations or orders for providing specialized medical assistance to the child, when applicable. All supplies listed on supply list or supply fee. 5

I, parent or LAR of, DOB, have received and agree to (Student s Name) (Student s Birthdate) follow all operational policies set within Mosaic Mother s Day Out Policy Manual.

Tuition can be paid by cash, check, money order, auto-draft, or through online giving at www.mosaicabilene.com.

6 I, parent or LAR of, DOB, have received and agree to (Student s Name) (Student s Birthdate) follow all operational policies set within Mosaic Mother s Day Out Policy Manual. I also understand that my tuition is paid to hold a spot in the classroom, and must be paid in-full, regardless of my child s voluntary attendance. Tuition can be paid by cash, check, money order, auto-draft, or through online giving at Please select your chosen schedule and any additional options and/or discounts that apply: Summer Registration Fee: Must be paid to reserve spot $25 per child Monday Thursday: 0 18 months: $100 / week 19m 5th Grade: $90 / week Two-day Schedule: 0 18 months: $55 / week 19m 5th Grade: $50 / week Multi-child Discount: Friday add-on or Friday Only: $5 / week per additional child $25 / week DATE OF ADMISSION: DATE OF WITHDRAWAL: I understand that my signature below represents my agreeance to the statements listed above. I also understand that failure to follow operational policies listed within the Policy Manual may be terms for expulsion from the program. Parent Signature: Date: 6

7 ADMISSION INFORMATION - Mosaic Church Mother s - Director: Ashley Neyhart Student s Information: GENERAL INFORMATION Full Name: DOB: Home Address: City:, TX Zip: Parent or Guardian Name(s): Parent Address: Parent 1 Contact #: Parent Name: Parent 2 Contact #: Parent Name: In case of emergency, please list an emergency contact you wish for us to reach if parents are not available: Name: Relationship to Student: Phone #: Phone 2: Other than guardians and the emergency contact listed above, I authorize Mosaic MDO to release my child to the following persons [children will ONLY be released after picture ID verification]: Name: Name: Name: Phone #: Phone #: Phone #: CONSENT INFORMATION Please check all that apply: 1. Transportation: Only to be provided for emergency care. 2. Water Activities: Water Table Play Sprinkler Play 7

8 3. Acknowledgement of receipt of the following information: Policy Manual [available online or in print in the Mosaic MDO Office] i. Includes: Discipline and Guidance Practices, Suspension and Expulsion Policy, Emergency Plans, Procedures for Conducting Health Checks, Safe Sleep Practices, Procedures for Contacting Director, Procedures for Parent Participation, Release of Children Procedures, Illness and Exclusion Criteria, Procedures for Dispensing Medication, Immunization Requirements, Meals and Food Practices, Procedures to visit Facility without prior Approval, and Procedures for Parents to Contact DFPS, Child Abuse Hotline, and the DFPS Website. 4. I understand that the following meals will be served / provided to my child while in care: Morning Snack Lunch [parents send lunch daily] Afternoon Snack 5. My child will be in care at Mosaic MDO on the following days during regular hours of operation: Monday Tuesday Wednesday Thursday Friday PERMISSION TO PHOTOGRAPH During the course of the year, we would like to use photographs of the children participating in the program for various purposes, including, but not limited to, art projects, memory boards, classroom décor, and the Mosaic website or Facebook page. Teachers and staff are forbidden to use photographs of the children for ANY use outside of MDO. Please check the appropriate box for consent to photograph: YES I give permission to Mosaic MDO to take photos of my child for purposes listed above. NO ONLINE PHOTOS I give permission to Mosaic MDO to take photos of my child to be used within the center only, but no online photos may be posted. NO Mosaic MDO does not have my permission to take photos or videos of my child. 8

9 AUTHORIZATION FOR MEDICAL ATTENTION If an emergency occurs, and my child s guardian(s) or emergency contact(s) cannot be reached to make arrangements for medical treatment, I authorize the person in charge at Mosaic MDO to take my child to: Physician Name: Phone #: Physician Address: City:, TX Zip: Emergency Care Facility: Phone #: ECF Address: City:, TX Zip: My signature below represents my acknowledgement of all consents listed above. My signature also represents consent to the Physician or Facility listed above to provide all necessary medical treatment to my child: Parent or LAR Name: Signature: SPECIAL NEEDS OR ALLERGIES Please list any special needs that your child may have. Special needs include, but are not limited to, environmental allergies, food allergies or intolerances, existing illnesses, previous serious illnesses, any mental health or behavioral diagnoses or concerns, hospitalizations during the past 12 months, any long-term medication prescriptions, or any other information you feel is pertinent for providing the best possible care to your child: Does your child have any diagnosed food allergies? YES NO Emergency Plan Submitted on: If yes, please list diagnosed food allergies: Child day care operations are public accommodations under the American with Disabilities Act (ADA), Title III. If you believe that such an operation may be practicing discrimination in violation of Title III, you may call the ADA Information Line at or

10 ADMISSION REQUIREMENTS Your child will not be admitted for attendance to Mosaic Mother s Day Out until all of the items listed below have been submitted to the office. 1. Completed Enrollment Packet as provided by Mosaic Church Mother s Day Out. 2. Immunization records printed or signed by a health care professional. a. If you have declined immunizations, a signed and dated affidavit stating that you have declined immunization for reason of conscience, including religious belief, on the form described by Section Health and Safety Code must be submitted. 3. Statement of health provided by a health care professional stating that child has been seen within the past 12 months, and is able to take part in the day care program. a. MUST BE PROVIDED WITHIN 90 DAYS OF ADMISSION. Additional information regarding immunizations can be found by visiting the Texas Department of State Health Services website: ADDITIONAL REQUIREMENTS FOR CHILDREN AGE 4 AND UP 1. Vision Exam Results 2. Hearing Exam Results CHICKENPOX (VARICELLA) If your child has had the chickenpox disease, they are not required to have the varicella vaccine. Please complete the following statement IF YOUR CHILD HAS HAD CHICKENPOX: My child was diagnosed with chickenpox on, and does not require the varicella vaccine. GANG-FREE ZONE Under Texas Penal Code, any area within 1,000 feet of a childcare center is a gang-free zone, where criminal offenses related to organized criminal activity are subject to harsher penalties. PRIVACY STATEMENT For more information regarding privacy and security, visit 10

11 SIGNATURES My signature below represents that all information provided within this document is accurate to the best of my knowledge. My signature also represents my acknowledgement and consent of all information listed within this document, and within the policy manual. I understand that my child will not be admitted to attend Mosaic MDO until all required documents and the annual registration fee are submitted to the office. Parent or LAR Signature: Center Designee Signature: Date: Date: SUMMER AUTO-DRAFT INFORMATION - OPTIONAL First Name: Last Name: Billing Address: City: Phone Number: Zip Code: Please select the date(s) that you would like your tuition to be drafted each month: Weekly tuition on Monday of Each Week ¼ of full-summer tuition on each date listed below: June 15 th ~ July 1 st ~ July 15 th ~ August 1 st ¼ Payment Amounts: M-Th: Nursery $250 / 19m & up $225 2 Day: Nursery $ / 19m & up $125 Payment Information: ***Please Note: Add $56.25 to each payment for Fridays Account Holder s Name: Credit Card Account Number: Expiration Date: Security Code: Please review the above information and make sure everything is correct. By signing below, you are authorizing Mosaic Church of Abilene to use NCS Services to deduct the specified amount from your selected card at the selected frequency. You may request to stop auto-draft at any time, but you must provide Mosaic Church no less than 5 days notice prior to your next draft date. Card Holder s Signature: Date: 11

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13 NURSERY ENROLLMENT PACKET To be completed for students 0 18 months. Parents, Certain information in this packet will need to be updated MONTHLY until your child reaches 19 months. Thank you for your cooperation with this matter! Mosaic MDO STUDENT NAME: DOB: INITIAL DATE OF COMPLETION: 13

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16 INFANT CARE INSTRUCTIONS The following information is needed to ensure the best quality care for your child. This form will need to be signed and/or updated on a monthly basis. DOES INFANT USE A PACIFIER? YES NO FEEDING INSTRUCTIONS: INFANT USES: FORMULA ONLY BREASTMILK ONLY BOTH TYPE OF FORMULA (BE SPECIFIC): INFANT PREFERS BOTTLES: WARM ROOM TEMP COLD -BOTTLE HEATING INSTRUCTIONS: -INFANT WILL DRINK OUNCES ON DEMAND EVERY HOURS. ADDITIONAL DRINKS / FOODS THAT MY CHILD EATS: -JUICES: -CEREALS: -VEGGIES: -FRUITS: -MEATS: ***FOOD ALLERGIES: OTHER HELPFUL INFORMATION REGARDING FEEDING INFANT: *ONE BOTTLE PER FEEDING NEEDS TO BE SENT DAILY (3 FEEDINGS = 3 BOTTLES) 16

17 DAILY SCHEDULE: INFANT S TYPICAL DAILY SCHEDULE: 7 8 AM PM 8 9 AM 12 1 PM 9 10 AM 1 2 PM AM 2 3 PM SLEEPING INSTRUCTIONS: *MOSAIC MDO WILL FOLLOW THE OPERATIONAL POLICY ON INFANT SAFE SLEEP (DFPS FORM 2550). IF YOU HAVE ALTERNATE REQUESTS FOR YOUR CHILD S SLEEP, AN INFANT SLEEP EXCEPTION (DFPS FORM 2710) WILL NEED TO BE COMPLETED AND SIGNED BY A LICENSED HEALTH CARE PROFESSIONAL. DIAPER CHANGE INSTRUCTIONS: *IF YOU WISH FOR CREAM, POWDER, OINTMENT, OR LOTION TO BE USED ON YOUR CHILD WHILE AT MDO, YOU MUST PROVIDE A LETTER IN WRITING STATING TIMES AND DIRECTIONS OF USE. ALL SUPPLIES MUST BE LABELED WITH YOUR CHILD S NAME. I CAN [PLEASE CHECK ALL THAT APPLY]: ROLL OVER SIT WITH ASSISTANCE SIT PULL MYSELF UP CRAWL WALK HOLD MY OWN BOTTLE OTHER: 17

18 PLEASE PROVIDE ANY OTHER INFORMATION THAT MAY BE HELPFUL: SIGNATURE PAGE MUST BE SIGNED EACH MONTH! PARENT SIGNATURE DATE PARENT SIGNATURE DATE PARENT SIGNATURE DATE PARENT SIGNATURE DATE PARENT SIGNATURE DATE PARENT SIGNATURE DATE 18

ADMISSION INFORMATION

Texas Dept of Family and Protective Services ADMISSION INFORMATION Form 2935 Aug 2010 / Pg 1 of 3 Operation Name The Stepping Stone Director s Name Ashley Stock Child s Full Name Child s of Birth Child