McNeilly Center For Children Enrollment Form

MCNEILLY CENTER FOR CHILDREN

100 Meridian Street, Nashville TN 37207 . Phone : (615) 255 2549
CHILD'S INFORMATION:
Child Name*
DOB*

MonthDayYear
Date
Age
Gender*
Special Needs
PARENTS' INFORMATION
Parent or Guardian*
If other relationship , please name.
Last Name*
First Name*
Address Line 1*
Address Line 2
City*
State*
Zip Code*
Phone (Cell)*
Phone (Home)
Phone (work)
Email*
example@example.com
Employer /School
Parent or Guardian
If other relationship , please name.
Last Name
First Name
Address Line 1
Address Line 2
City
State
Zip Code
Phone (Cell)
Phone (Home)
Phone (Work)
Email
Employer / School
Contact person @ work/school if we are unable to reach Father
Name
Phone #
All information is subject to verification

Other Children in the family/household:
Name
DOB

MonthDayYear
Name
DOB

MonthDayYear
Name
DOB

MonthDayYear
Emergency Contacts Other than Parents

People you authorize to act for you in an emergency situation and are authorized to pick up child. Picture ID is required for identification.
Name
Relation
Phone (Cell)
Phone (Home)
Phone (Work)
Name
Relation
Phone (Cell)
Phone (Home)
Phone (Work)
- If someone other than the parent or another authorized adult on your child's pickup list is picking up your child, you must notify the center in writing. If it is an emergency situation, you may notify the center by phone.
- No one under the age 18 is permitted to pick up your child unless you provide the center with a letter explaining the hardship. This letter must be signed and notarized.
- Children will not be release to anyone under the influence of any drugs or alchohol.

McNeilly Center for Children Policies
Name of Child Physician*
Clinic
Office Phone
Address
City
State
Zip
YesNo
Please provide below insurance information if not on file.
Name of Insurance company
Primary Policy Holder
Policy #
Expiration Date

MonthDayYear
Date
I hereby give my consent McNeilly Center For Children to call for emergency services. Services may be administered and my child may be transported to the nearest hospital is the situation warrants. I agree to keep current contact information on file with McNeilly.
Parents Signature*
Date*

MonthDayYear
Date

McNeilly Center for Children Policies
- The undersigned parent or guardians herby register their child for the McNeilly Center for Children.
- We accept DHS certificates. Those who are not for a certificate might be eligible for our sliding scale with appropriate documentation.
- Signing states that you are required to cooperate with McNeilly Staff and intervention programs to meet the needs of their child. Failure to cooperate with McNeilly Center and intervention programs can result in dismissal of the program. See our Discipline Policy in the handbook if you have question.
Please initial the following statements. By initialing you are agreeing to each
I give permission for my child to be photographed or videotaped while at the center for in house relations purposes or for others to interpret the school program. This does not include pictures home through Brightwheel.*
Initials
I understand that I will be notified in advance and will be asked to sign a release for my photos that might be release outside of the McNeilly Center.*
Initials
I understand that the information in my child's file will be made available for the Tennessee of Human Services, the Metro Health Department, and the Tennessee Department of Services if requested by these agencies.*
Initials
I understand that I must provide complete financial information for scholarship/sliding scale rate full pay tuition will be applied.*
Initials
I have received a copy of the Summary of Licensing Requirements found in the handbook.*
Initials
I have received a copy of the Family Handbook.*
Initials
I have turned in all needed forms and documents including: (Child will not be able to start until they are)*
Initials
- Child's file
- Birth certificate
- Shot Record
- A copy of their insurance card
- A copy of the parents ID
I agree to abide by the policies and procedures described in the parent handbook.*
Initials
Parent Signature*
Date*

MonthDayYear
Date

McNeilly Center for Children Arrival and Departure Time
Parent Information
Parent Name
Place of Employment
Time of Work
Name of School
Time of School
Child's Arrival Time
Childs Departure Time
We ask that children are only here while you are working. Please make sure that you are not abusing your child care.

All children must arrive by 9 AM and leave by 5:30 PM.
Parents Signature
Date

MonthDayYear
Date

McNeilly Center For Children

We are require by law to report and suspected child abuse and/or neglect to the Department of Children's Services.

Signs include unexplained burns, bites, bruises, broken bones or black eyes may signal the presence of child abuse or neglect. Also, child:
- Shows sudden changes in behavior or school performance.
- Has not received help for physical or medical problems brought to the parents' attention.
- Has learning problems that cannot be attributed to specific physical or psychological causes.
- Is always watchful, as though preparing for something bad to happen.
- Lacks adult supervision.
- Is overly compliant, passive or withdrawn.
- Comes to school or other activities early, stays late and does not want to go home
NO CHILD WILL BE RELEASED INTO THE CARE OF SOMEONE WHO IS INTOXICATED BY DRUGS OUR ALCOHOL.
Parents Signature*
Date*

MonthDayYear
Date

Parent Rights and Responsibilities

You have the RIGHT to:

1. Be treated with courtesy and respect.

2. Be informed of the basic requirement for the use of childcare services.

3. Expect that information you share will be held in confidence. Our respect for your privacy is limited by the following: when there is a threat of harm to self and or others; when funding agency staff review records, if you are enrolled in a partner agency and when supervisory and consultative help is sought from other McNeilly staff.

4. Expect that information that is requested by an outside agency will ONLY be shared if you give your written permission to the Child Care Center.

5. Review your own official case record.

6. Choose whether or not you enroll your child in McNeilly Center for Children's program and have the right to terminate services at any time.

7. Make a complaint and appeal adverse decisions and be informed of how to file a complaint or grievance and have a right to a supervisory hearing.

8. Refuse a recommended service.

You are RESPONSIBLE for:

1. Providing information that is necessary for providing care to your child.

2. Following program rules (e.g., immunizations, being on time for dropping off and picking up children).

3. Keeping information you provided to the center up-to-date.

4. Cooperating with ChildCare staff and treating the staff with courtesy and respect.

5. Providing a 2 week notice if you decide to cancel childcare services.

6. Keeping children out of childcare when ill.

7. Keeping childcare fees current.

Failure to assume these responsibilities could result in services being denied, being terminated from service and/or accounts turned over to collections.

I have been informed of the "Parents Rights and Responsibilities", received a copy and I understand my rights and responsibilities.
Parent Signature*
Date*

MonthDayYear
Please verify that you are human*
Should be Empty:

MCNEILLY CENTER FOR CHILDREN

CHILD'S INFORMATION:

PARENTS' INFORMATION

Please provide below insurance information if not on file.