WATCH ME GROW FAMILY REGISTRATION FORM SHEET 1 OF 6 Parent/Guardian Information Registration Mother/Guardian First Name: M.I. Last Name: Date of Birth: Address (please include city, state and zip code): Occupation: Home Phone: ( ) Employed By: Office Phone: ( ) Work Address: Work Hours: Cell Phone: ( ) [ ] Custodial Parent (If married, mark both parents) Mother s SS#: Email: Driver s License #: Preferred PIN number for checking in/out (4 digits, numbers only) 1 st choice 2 nd Choice Marital Status:[ ] Married [ ] Single [ ] Divorced [ ] Separated [ ] Widowed [ ] Other Father/Guardian First Name: M.I. Last Name: Date of Birth: Address (please include city, state and zip code): Occupation: Home Phone: ( ) Employed By: Office Phone: ( ) Work Address: Work Hours: Cell Phone: ( ) [ ] Custodial Parent (If married, mark both parents) Mother s SS#: Email: Driver s License #: Preferred PIN number for checking in/out (4 digits, numbers only) 1 st choice 2 nd Choice Marital Status:[ ] Married [ ] Single [ ] Divorced [ ] Separated [ ] Widowed [ ] Other Child Information 1 st Child First Name: M.I. Last Name:
WATCH ME GROW FAMILY REGISTRATION FORM SHEET 2 OF 6 Child Information - Continued 2 nd Child First Name: M.I. Last Name: 3 rd Child First Name: M.I. Last Name:
WATCH ME GROW FAMILY REGISTRATION FORM SHEET 3 OF 6 Child Information - Continued 4 th Child First Name: M.I. Last Name: 5 th Child First Name: M.I. Last Name:
WATCH ME GROW FAMILY REGISTRATION FORM SHEET 4 OF 6 Emergency Contacts & Authorized Pickup Persons: (You must list a minimum of 2) 1st Contact/Pick Up Name: Address: Relationship to the Child: PIN for check in/out (4 digits, numbers only) 2nd Contact/Pick Up Name: Address: 3rd Contact/Pick Up Name: Address: 4th Contact/Pick Up Name: Address: 5th Contact/Pick Up Name: Address: 6th Contact/Pick Up Name: Address: 7th Contact/Pick Up Name: Address: 8th Contact/Pick Up Name: Address: Child Care Licensing - (Las Vegas Child Care Licensing Office 4180 S. Pecos, Suite150 Las Vegas, NV 89121 702-486-3822) Parent/Guardian Notification of NRS.178 Child Care Facility required to maintain certain information; reporting of information to parents and guardians; notice of right to information: I,, (Parent/Guardian) am aware that I have the right to request and review any complaints the facility has received within the last 12 months of my child s(ren s) enrollment. Signature of enrolling Parent/Guardian: Permission to Release Information I understand that the time my child(ren) is in care at this facility the staff may be asked for information regarding my child I hereby (circle one) GIVE / DO NOT GIVE permission to release information to official persons only from schools, health care personnel, welfare or other governmental officials. I realize that the bureau of Services for Child Care Licensing has access to my child s record as the licensing agent. Signature of Parent/Guardian: Chemical Air Fresheners and Pesticides Please be advised that Watch Me Grow uses Professional Pesticide Service Monthly. Additionally, the facility may use chemical air fresheners during the hours of operation.
WATCH ME GROW FAMILY REGISTRATION FORM SHEET 5 OF 6 Tuition / Payment Information Financial Agreement: Type of Attendance (please circle): Full Day (more than 5 hours per day) Part Day (less than 5 hours per day) Annual Registration Fee: (please initial indicating that you have read and agree to terms) A (non-refundable) fee of $75.00 is due upon your child s initial registration and each subsequent year on the anniversary date of your child s enrollment. If tuition is not paid on the first day of the week, the child will not be allowed to return until payment is made. Glove Fee: (please initial indicating that you have read and agree to terms) In order for Watch Me Grow to maintain current tuition rates the following glove fee will be applied monhly to my childs tuition: Non potty trained children $12.00 per month Potty trained children $5.00 per month Payment Schedule: (please initial indicating that you have read and agree to terms) Based on the above contract I agree to pay $ on the first day of my child s week each week. Payments received after the 1 st day of my child s week will result in a $25.00 late fee. If tuition is not paid by the third day of the child s week, the child will not be allowed to return until payment is made. Method of Payment: I choose the following method of payment (please initial beside choice) *****PERSONAL CHECKS ARE NOT ACCEPTED***** Cash Payment Online Payment: Watch Me Grow will provide an account number needed for enrollment to the online bill payment system. Thereafter, I agree to log on weekly to www.billerportal.com/ebpp/sites/watchmegrow/default.asp to pay my account balance. Credit/Debit Payment: I agree to pay my account balance by credit/debit transaction on or before the first day of my child s week. I further understand that there will be an additional fee of $10.00 added to my account for each credit/debit transaction. Change in Schedule: (please initial indicating that you have read and agree to terms) Tuition is set by the contract that is signed upon enrolling the child in the program. The contracts may be adjusted from time to time as needed with a two week notice of intent to change services. Schedule changes will be at the discretion of management based on space availability. If my child attends other than the above contracted schedule, additional charges will be added to my child s account. Vacations, Absence and Holiday s: (please initial indicating that you have read and agree to terms) Vacations and Absences will be charged at the scheduled number of days the child is enrolled per week. All days reserved are paid whether the child attends or does not attend. Children are eligible for one week of vacation the first year following 6 months of continuous enrollment. A week is defined as the scheduled number of days the child is enrolled. After one year of continuous enrollment and the annual registration fee is paid, the child is allowed an additional vacation week (2 vacation weeks per enrollment year). Vacation days may not be carried over to the next enrollment year. A 2-week written notice is required prior to the vacation week being taken. WMG observes New Year s Day, Memorial Day, July 4th, Labor Day, Thanksgiving Day and the day after Thanksgiving, Christmas Eve Day and Christmas Day. If holiday falls on Saturday, the holiday is observed on the previous Friday. If holiday falls on Sunday, the holiday is observed on the following Monday. All holidays will be charged at the regular rate. No fee adjustment is made for designated holidays. Late Pick Up Fees: (please initial indicating that you have read and agree to terms) There will be a $5.00 fee added (per child) for the first minute and $1.00 per minute for every additional minute if pick-up takes place after closing. This fee is non-negotiable and is the responsibility of all parents. Withdrawal: (please initial indicating that you have read and agree to terms) A 2-week notice is required for withdrawal. Tuition must be paid during this 2 week withdrawal period whether or not the child attends. If tuition is delinquent and the child is not allowed to return, the parent and/or guardian will still be charged the delinquent balance in addition to 2 the week tuition, as is required to withdraw. We are not responsible for lost or damaged personal items. I agree to pay all attorney and collection costs incurred by Watch Me Grow, if I should default on the terms and conditions of this Financial Agreement. I have read this Financial Agreement, I agree to the terms stated above. Parent s Signature: Thank You!
WATCH ME GROW FAMILY REGISTRATION FORM SHEET 6 OF 6 Familyregistrationcard09092013