Caterpillars to Butterflies Enrollment Form

Enrollment Application Form
Expected Entrance Date Date*
Age    Age*   Birthdate     Date*
Hours of Care needed (Drop-off/Pick-Up)     Time    to     Time
Child's Name*

First NameLast Name
HispanicLatinoNon-HispanicBlack/African AmericanCaucasianAmerican Indian/Alaska Native PacificPrefer not to sayAsianOther
Parent's Information
Mother's Name*

First NameLast Name
Social Security #
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail*
example@example.com
Home #*
Format: (000) 000-0000.
Cell #*
Please enter a valid phone number.Format: (000) 000-0000.
Employer's Address*

Street Address

Street Address Line 2

CityState

Zip Code
Hours of Employment

Hour Minutes

AM/PM Option

-
until
Hour Minutes

AM/PM Option
Father's Name*

First NameLast Name
Social Security #
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail
example@example.com
Home #
Format: (000) 000-0000.
Cell #
Please enter a valid phone number.Format: (000) 000-0000.
Employer's Address

Street Address

Street Address Line 2

CityState

Zip Code
Hours of Employment

Hour Minutes

AM/PM Option

-
until
Hour Minutes

AM/PM Option
Both ParentsMotherFatherOther
Both ParentsMotherFatherOther
Emergency Contact

Pick-Up/Drop-Off Person(s) Information
Name*

First NameLast Name
Relation to Child*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail
example@example.com
Home #
Format: (000) 000-0000.
Cell #
Please enter a valid phone number.Format: (000) 000-0000.
Name

First NameLast Name
Relation to Child
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail
example@example.com
Home #
Format: (000) 000-0000.
Cell #
Please enter a valid phone number.Format: (000) 000-0000.
Name

First NameLast Name
Relation to Child
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail
example@example.com
Home #
Format: (000) 000-0000.
Cell #
Please enter a valid phone number.Format: (000) 000-0000.
Medical History
Doctor's Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState

Zip Code
Business #
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Insurance ID#:*
Insurance Company*
Insurance Group#:*
YesNo
Attentiion-Deficit/Hyperactivity Disorder (ADD or ADHD)AutismSpeech or language impairmentOther
My child has the following special needs
Please include any medical conditions we should be aware of.
YesNo
List Allergies *
List their reactions and/or food restrictions.
Medications Prescribed
For long-term continuous use and/or has the following pre-existing illness, allergies, or health concerns.
AsthmaBronchitisChicken PoxDiabetesFainting SpellsFrequent Ear InfectionsHeart DiseaseHepatitisImpetigoLiceMeaslesMumpsPolioRing WormScarlet FeverSkin RashStreptococcusTuberculosisWhooping CoughOther
PLEASE NOTE: You are required to provide your child's immunization records, in addition to, filing out all of the information above.
Emergency Medical Authorization
Should (child's name)First Name*   Last Name*   Date of birth      suffer an injury or illness while in the care of Caterpillars to Butterflies Inc. and the facility is unable to contact the parents immediately, it shall be authorized to secure such medical attention and care for the child as may be necessary. I (We) shall assume responsibility for payment for services.

Parent/Guardian: Signature*
Date:   Date*

Facility Director/Administrator/Person-In-Charge:    Signature
Date:   Date
Medication Policy
Medication Policy: Both prescription and non-prescription medication shall be accepted only in its original containers: Presciption medication shall be labeled with full pharmacy label. Emergency Medical Care: This authorizes Caterpillars to Butterflies Learning Tree to secure Emergency medical care for my/our child when I/we cannot be immediately reached at the time of emergency. I/we will be responsible for the any emergency medical charges upon receipt of the statement is the preferred doctor/clinic/hospital. *

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Administer Prescription Medicine: I/we authorize Caterpillars to Butterflies Learning Tree to administer prescribed medicine to my/our child as specified in the prescription's directions for administration.*

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Administer Over-The-Counter Medicine: (Administer only in accord with the appropriate standards for licensure) I/we authorize Caterpillars to Butterflies to administer over-the-counter medicine to my/our child as specified in written instructions. Over-the-Counter (non-prescription ) medication shall be clearly labeled with the child's name . The container shall be in such condition that the name of the medication and the directions for use are clearly readable *

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Upload Medical Form here (Epipen, medications, allergies etc.)*

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Medical Insurance Card ( front & back) *

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Trips, Excursions, and Public Park Facility Policy
TRIPS, EXCURSIONS, AND PUBLIC PARK FACILITIES: I/we authorize Caterpillars to Butterflies to take my/our child on walking trips, special excursions, and to nearby public park facilities. I/we also authorize the child to ride as a passenger in the vehicle owned or leased by the above-named person(s). I/we understand all such trips are under the supervision of the above-named person(s) and that health and safety precautions are taken in compliance with DCFS standards for licensure. Signature*

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Birth Certificate Notification Letter
This faculty is required by the Department of Children and Family Services to provide you with this written notice requesting that you provide a certified copy of your child’s birth certificate, within the first 30 days of enrollment. We will make a duplicate copy and return the original copy to you. If a certified copy of a birth certificate is not available, you must submit a passport, visa, or other governmental documentation as proof of a child’s identity and age and an affidavit or notarized letter explaining the inability to produce a certified copy of the birth certificate. This facility is required by law to notify the Illinois State Police or local law enforcement agency if you fail to submit proof of the child’s identity within the 30 day time frame. If we must contact the Illinois State Police or local law enforcement, we are required by law to notify you in writing, that we have contacted them as required, and you have 10 additional days to comply by submitting the required documentation. We are also required to report to the Illinois State Police or local law enforcement agency any affidavit received which appears inaccurate or suspicious in form or content. The center shall flag the record of a child enrolled at the daycare who is reported by the Illinois State Police as a missing person, and shall immediately report to the Illinois State Police any request concerning flagged records or knowledge as to the whereabouts of any missing child. [325 ILCS 50/5] If you have any questions about this procedure please feel free to contact us.

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Upload Birth Certificate*

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Biting is, unfortunately, not uncommon for toddlers. Some children and many toddlers communicate through this behavior. However, biting can be harmful to other children and to staff. This biting policy has been developed with both of these ideas in mind. As a childcare provider, we understand that biting, unfortunately, does occur. Our goal is to help identify what is causing the biting and resolve these issues. If the issue cannot be resolved, this policy serves to protect the children that are bitten. If a biting incident occurs, state regulations require that the parent of the child biting and the parent of the child who was bitten be contacted. Names of the children are not shared with either parent. When Biting Does Occur: Our staff strongly disapproves of biting. For the child that was bitten: 1. The teacher will comfort the child. First aid is given to the bite. Ice will be provided and the area is to be cleaned with soap and water and covered with a bandage if needed. 2. The teacher will immediately notify office staff, at which time parents are notified. 3. An Incident Report will be completed, documenting the incident. 4. Parents may request a conference with the Director to discuss any concerns/questions. For the child that bit: 1. The teacher will firmly tell the child “NO! DO NOT BITE!” and show the child how he/she hurt their friend. 2. The child may be placed in time out for no longer than the child’s age (one year old, one minute) or removed from the situation. 3. The parents are notified. 4. An Incident Report will be completed, documenting the incident.

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Biting Policies
Late Policy
Late Pick Up: Children must be picked up by 5:30 p.m. When a parent or guardian is late picking up his or her child, the child will remain on site at the school. The site staff will work with the designated School Director to contact the parents. We will use the child’s emergency numbers listed on the enrollment form to contact the names listed on the enrollment form. For this reason, it is imperative that you provide CB Learning Tree with up-to-date emergency contact names and telephone numbers and written notification of any changes in your child’s emergency contact information throughout the course of the year. The person picking up the child is required to sign documentation acknowledging the late pick up and have proper ID with them. Staff will make every attempt to reach the parent, guardian or authorized persons until the last staff member is scheduled to leave. Attempts to reach the parent, or guardian, or authorized person listed on the enrollment form will be made every 10 minutes, then we will contact appropriate governmental authorities such as the DCFS hotline, police, etc. Late fees: Minutes $2 per minute after five minute grace period Fees Charged are due same day and no later than the next school day. I have read and understand Caterpillars to Butterflies Learning Tree Late Policy. I will adhere to all of the policy rules.*

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Discipline Policy
Discipline will be dealt with by redirecting the child to a new activity or area, or when necessary, child may need a "Time Out." "Time Out," is removing the child from the situation and selecting an isolated area where they can sit and watch the group. After regaining composure children can return to group activities. "Time Out," should not be prolonged and the child's age is taken into consideration time permitted for "Time Out." "Time Out," is not a form of punishment it is a reinforcement measure for inappropriate behavior. Punishment is not discipline! Privileges will not be denied with regards to food, outdoor time, or activity time. It may be necessary, however, for staff to guide the child in the choice of activity to which they can return. As Dr. James Hymes said, "Discipline is the slow, bit-by-bit, time consuming task of helping children to see the sense in their actions." It is the responsibility of each childcare worker to teach children to understand and discipline their own responses. Childcare workers must always be consistent. Help children work through their behaviors is much more rewarding then responding negatively to their behavior.

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Photo Release Form
We, at Caterpillars to Butterflies Learning Tree, would be from time to time taking photos of students during daily school activities. Through our ProCare app parents and guardians will receive some videos and photos of your child/ren throughout the week. In this regard, we seek your consent for the publishing or use of photos which your child may be included. The photos will be used for bulletin boards, and/or marketing updates posted via ourschool social media platforms and website, and/or within the walls of the daycare premises. Should you decided to take back your authorization later on, you may do so by writing to us. For protection of privacy of the child, we guarantee that names will not be included.*

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We, at Caterpillars to Butterflies Learning Tree, want the best for your child and would like to make sure that we are the best fit program for you. Each enrollee will be assessed for the first two weeks of school and if we are unable to meet your child's needs, we will offer a referral *

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I have read, print, and signed the Birth Certificate Notification LetterI have read, print, and signed the Biting PolicyI have read, print, and signed the Late PolicyI have read, print, and signed the Medication PolicyI have read, print, and signed the Discipline PolicyI have read, print, and signed the Tuition Fee PolicyTrips, excursions, and public park facility PolicyPhoto Release Form
List your academic goals for your child?
What are some of your child's favorite activities, toys, books, and/or games?
Napping habits?
How did you hear about us?*
YesMaybeNo
Suggestions if any for further improvement:
Signature

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Note:

The School Supply List & Yearly Online calendar is available via our school website at cb-learningtree.com
Should be Empty:

Enrollment Application Form

Parent's Information

Emergency Contact

Medical History

Emergency Medical Authorization

Medication Policy

Trips, Excursions, and Public Park Facility Policy

Birth Certificate Notification Letter

Biting Policies

Late Policy

Discipline Policy

Photo Release Form

Note: