Registration Form

Student Registration Form

Fill out the form carefully for registration if something does not apply please insert N/A in the answer box.
Student Name

First NameMiddle NameLast Name
Student Nickname(s):

Preferred NamePreferred name
Birth Date

MonthDayYear
Gender
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mothers Name

First NameMiddle NameLast Name
Mother's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Fathers Name

First NameMiddle NameLast Name
Father's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mother's Email
example@example.com
Father's Email
example@example.com
Mother's Mobile Number
Father's Number
Mother's Work Number
Father's Work Number
Mother's Company Name:
Father's Company Name:
Mother's Work Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Father's Work Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of Persons/Agency having legal custody of the child
Address of Person or Agency Having custody of the child/Children

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number of Person or Agency Having Legal Custody of Child:
Please enter a valid phone number.
Does Both Parents Have Legal Custody of Child?
Previously attended or Other Daycare/School currently Attending:
Previously attended or Other Daycare/School currently attending Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number to Previously Attended or Other Daycare/School Currently attending:
Please enter a valid phone number.
Desired Start Date:*

MonthDayYear
Date

Student Name

First NameMiddle NameLast Name
Student Allergies or food sensitivities:
Must be accompanied by Allergy action plan if noted on Child's physical form!
Chronic Illnesses/Diseases/Diagnosis/Ailments/Pertinent Information/Accomodations Needed:
Additional Comments
Emergency Contact 1:

First NameLast Name
Emergency Contact 1 Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact 1 Email:
example@example.com
Emergency Contact 1 Phone Number:
Please enter a valid phone number.
Emergency Contact 2 Name:

First NameLast Name
Emergency Contact 2 Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emerrgency Contact 2 Email:
example@example.com
Emergency Contact 2 Phone Number
Please enter a valid phone number.
Name of Persons Authorized to Pickup/Visit or inquire about the Child:
Name of Persons NOT Authorized to Pickup/Visit or inquire about the Child:
Please Upload Custodial Agreement if a Parent is not allowed to pick up the Child:

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Physician Name:

First NameLast Name
Physician Office Name:
Physician Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Physician Phone Number
Please enter a valid phone number.
Physician Fax Number
Please enter a valid phone number.

Days wanting Care:

MondayTuesdayWednesdayThursdayFriday
Arrival on Monday:

Hour Minutes

AM/PM Option
Arrival on Tuesday:

Hour Minutes

AM/PM Option
Arrival on Wednesday:

Hour Minutes

AM/PM Option
Arrival on Thursday:

Hour Minutes

AM/PM Option
Arrival on Friday:

Hour Minutes

AM/PM Option
Departure on Monday:

Hour Minutes

AM/PM Option
Departure On Tuesday:

Hour Minutes

AM/PM Option
Departure On Wednesday:

Hour Minutes

AM/PM Option
Departure On Thursday:

Hour Minutes

AM/PM Option
Departure On Friday:

Hour Minutes

AM/PM Option
I agree to pick up or arrange to have my child picked up as soon as possible when notified that he or she develops symptoms of a communicable disease; an oral temperature of 99.6F or an armpit temperature of 100.6; or recurrent (2 times or more) vomiting or diarrhea. The parent(s)/guardians agree to inform the center within 24 hours of the next business day after his child or any member of the immediate household has developed a reportable communicable disease, as defined by the State Board of Health, except for life threatening diseases which must be reported immediately.Should my child develop Lice and is in the child care center I will agree to pick up or arrange to have my child picked up as soon as possible and keep my child home until all nit signs have cleared. If my child develops Lice away from the child care center I will keep my child home until all nit signs have cleared and will notify the Director of Lilly's Learning Pad as soon as possible. I understand that in case of an emergency due to illness the provider will contact the parent(s) or guardian; if the parent(s) or guardian is not available or cannot be reached, the provider will notify the designated emergency contact to pick up the child. In these instances where a child is asked to be picked up the child needs to be picked up within 30 minutes and no more than 1 hour of the parents or emergency contact being notified or local authorities will be called. I authorize the Child Day Care Center to obtain immediate medical care for my child if an emergency occurs and I cannot be located immediately. I have completed, signed, and dated the child’s emergency medical authorization form. I authorize the Child Day Care Center to provide or arrange for emergency transportation to my preferred Medical facility/Hospita or the nearest emergency medical facility if an emergency occurs and I cannot be located immediately. I understand the requirement for paid staff to report suspected child abuse 63.1-248.3 of the Code of Virginia. I authorize my child to participate in certain community activities. List such activities, times and methods of transportation: The local park In the surround area: Children will be taken to play in the park daily as long as weather and conditions are permitting.Neighborhood walks: when unable to go to the playground for whatever reason i.e closure, danger or hazardous environment, over crowding or any reason deemed acceptable by the owner/director of the facility the children may go on neighbor hood walks around the center withing 1 mile radius.I agree to allow a provider, substitute provider or an assistant to transport my child as necessary. I have reviewed the discipline policy including the acceptable and unacceptable discipline methods with the Child Day Care Center. If you agree please select I agree from the drop down menu.*
If for some reason you disagree you may talk to the director. However, your start date may be delayed.
Preferred Medical Facility/ Hospital:
Address of preferred medical facility/hospital

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number to preferred medical facility/hospital
Please enter a valid phone number.
All payments must be made on the Friday before care each week. Any payments made after 11:00 a.m. Friday are subject to a late fee of $25.00 and $25 per additional day your payment is late.Parents are required to pay for holiday, sick days and vacations. Please review the holiday/vacation schedule carefully. Parents are responsible for provider vacations. when terminating childcare within 4 weeks of vacation time payment is still REQUIRED.Important vacation weeks and payment required below;Spring - No Payment ____ , Full payment ______, ½ payment _____Summer - No payment _____, Full payment _____, ½ payment _____Payments are required to pay for the summer and spring vacation if child uses any part of the spring or summer break of the summer program. Summer program begins on July 1st.Note: There will be closings periodically when weather is inclement, i.e. snow storms, ice storms, hurricanes, etc. Childcare provider will call as much in advance as possible to let you know. Registration fee :There is a $100 Registration fee to secure your child’s spot in the program-No cash refunds allowed- NO Exceptions; 4-week notice cannot include the unpaid summer vacation week. No spots will be held until the registration fee is paid. We can not gurantee any spots being available for your child/children unless this fee is paid. Payment of the registration fee is due with this completed application and supporting documents. Please see below where your registration fee can be paid.The registration fee is non-refundable.Termination of care requires a 4 week paid notice made in writing.There is also a $25.00 charge for all children to be included in the deposit for use of personal rest time mat. $ _____Tuition can also be made in conjunction with the registration fee please send me an email if you have made any childcare payments via the link below, the amount and how you would like it applied to confirm receipt of your payments. If you agree please select I agree from the drop down menu. *All tuition is NON-Refundable*
If for some reason you disagree you may talk to the director. However, your start date may be delayed.
Basic Rates and Payment PoliciesThe Payment fee shall be:- $295/week for infants ages 6 weeks – 24 months or $60/day for part time.- $275/week for ages 24 months- 3 years old and $250 for ages 3-6 or $55 per day for part time up to 3 days max per week. There is a 10% discount for siblings. The Payment fee shall be _______ per week for 2nd child.Child Care hours are from 7:30 a.m. -5:00 p.m. Additional Fees:There is a strict late fee charge for all those who pick up children past childcare hours. The fee is 1 minute past 5:00 p.m. to 5 minutes past is $5.00 every 5 minutes add $5.00 extra which is due at tour time of arrival the day you are late to be paid in cash. If you agree to this please input you agree.*
If for some reason you disagree you may talk to the director. However, your start date may be delayed.
Payments:

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USDYou may use this area to pay your registration fee $100 plus $25 Nap mat fee in addition to any tuition payments.
Termination Procedure:This contract may be terminated by either parent/guardian or child care director by giving 4 weeks written notice in advance of the ending date. Payment by parent/guardian is due for the notice period, whether or not the child is brought to the provider for care. The provider may terminate the contract without giving notice if the parent/guardian does not make payments when due or other acceptable and reasonable reasons to include but not limited to conflicts of interest, family-staff conflict, behavioral issues, and other reasons deemed reasonable and acceptable by the owner/Director. Failure by the provider to enforce one or mare terms of the contract does not waive the right of the provider to enforce any other terms of the contract. If you agree to adhere to the following please select I agree below. All Tuition or payments made to the center is NON-Refundable*
If for some reason you disagree you may talk to the director. However, your start date may be delayed.
Please upload a copy of your child’s Birth Certificate

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Childs Place of Birth _________________________ Birth Date __________________ Birth Certificate Number _______________________Date Issued ________Other Form of Proof of Age & Identity ______________________________ Date Documentation Viewed _______________________ Signature of Licensed Day Care Center Provider: _________________________________________________ Date: __________________________ Address: ________________________________________________________________________ Nothing needs to be entered here: PROVIDER USE ONLY!
Please Upload a Copy of your child’s medical insurance card front and back

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Please Upload a copy of your child’s Physical form and immunization records. If you do not have these documents please have your child’s physician fax them to us at 804-912-1288 for The Fan Campus and 804-303-3964 for Jacksonward Campus.

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Signatures:By signing this contract, parent(s) agree to abide by the written policies of the provider set forth in the parent handbook and on childcare contract. Parent(s) also acknowledge they have been given a copy and have thoroughly read the Parent Handbook. The provider may amend the policies by giving the parent(s) / guardian(s) a copy of the new or changed policies 1 week before they go into effect. If you agree please select I agree from the drop down menu below.*
If for some reason you disagree you may talk to the director. However, your start date may be delayed
Mother's Signature

Clear
Date

MonthDayYear
Father's Signature

Clear
Date

MonthDayYear
Date
Legal Agency or Persons having Legal custody of child Signature

Clear
Date

MonthDayYear
Date
Provider Signature:
Date:
Actual Start Date:
Date Child was withdrawn.

Payment Methods

Debit or Credit Card

Choose from one of the PayPal options to make your payment.

Should be Empty:

Student Registration Form