RKQ Registration Form

Raising Kings and Queens Application
Date of Application

MonthDayYear
Date
Date of Start

MonthDayYear
Date
Child's Name*

First NameMiddle NameLast Name
Age*
Sex*
Birth Date*

MonthDayYear
Home Address

Address

Street Address Line 2

City/ZipState / Province

Zip Code
Parent's Name*

First NameMiddle NameLast Name
Home Phone Number
Mobile Number
Work Number
E-mail
example@example.com
Emergency Contact Person
Contact's Phone Number
Beginning date needing care

MonthDayYear
Date
Hours:
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Times you plan to drop your child off

Hour Minutes

AM/PM Option
Times you plan to pick up your child

Hour Minutes

AM/PM Option
Doctor’s Name
Doctor's Phone Number
Dentist Name
Dentist's Phone Number

In accordance with state law, we must have on file the names, addresses, and telephone numbers of the individuals permitted to drop off or pick up your child from Raising Kings & Queens Center. If someone were to arrive without authorization, they would not be permitted to pick up your child.

CHILDREN CAN NOT BE RELEASED TO ANY PERSON WHO IS INTOXICATED OR IMPAIRED. SHOULD SUCH PERSON PERSIST IN COLLECTING A CHILD, AUTHORITIES WILL BE CONTACTED.

Please list below any person’s name, address, and telephone number who might call on your child, even in an emergency.
*may be dropped off or picked up by the following adults.

Raising Kings and Queens (RKQ) will accept enrollment of our child , into their center, we agree to the following.
1. To enroll our child beginning at a rate of per week (rates are subject to annual change).
2. I understand that this amount is due regardless of illness, holidays, or days that the center is closed.
3. I understand that if my account is 30 days past due the center has the right to terminate my child’s enrolment
4. I understand that RKQ will not assume responsibility for a child who has not been signed in when arriving for the day.
5. I agree to abide by the policies of the center
6. I give permission for RKQ to include in photographs for all programming media purposes
7. I confirm that I have read the RKQ admission and operating rules and agree to comply with them. I realize that I am liable for my children while in the care of RKQ. I understand that this statement releases RKQ and its employees from ALL LIABILTY.
8. I hereby grant permission for my child to use all of the play equipment and participate in all of the activities of the school, including water, fieldtrips, and transportation by RKQ Staff.
9. I understand that the director is to be notified in writing 2 weeks in advance, before child is to be withdrawn. Parents are required to pay for that time regardless of when the child leaves the center. Vacation time does not applied to 2-week notice.
10. I confirm that my child has not contracted or been exposed to any communicable disease within the 4 week prior to admission.
11. I hereby constitute and appoint RKQ my true and lawful attorney, for the purpose of authorizing emergency medical treatment to and the performance of any procedures determined to be necessary after consolation with emergency or family physician, on my child
12. Indiana code IAC 33-4.7-13, requires that all persons having reason to believe that a child is a victim of abuse or neglect shall make an immediate report to the local Child Protective Services. I understand that RKQ will therefore report any all suspected cases of abuse or neglect in accord either its legal obligation to do so.
13. On behalf of myself as custodian of the child enrolled at Raising Kings & Queens, by signing this parental agreement, I hereby agree on my behalf as well as on behalf of said child to make no claim against RKQ or its agents for any injury that may occur to said child, property, or myself with accepting the privileges granted by RKQ harmless with respects to any and all claim.
14. If after a reasonable period of time, it is found that a child unable to adjust to the center: the center reserves the right to request withdrawal of the child. This decision is left to the discretion of the director.
Parent's Signature*

Clear
Date

MonthDayYear
Date
Parent's Signature

Clear
Date

MonthDayYear
Date

Suspension and Expulsion Policy

Indiana early childhood education programs that are eligible to accept Child Care Development Fund (CCDF) vouchers are required to have a policy on suspension and expulsion. This policy is compliant with federal and civil rights laws.

• Teachers provide a purposeful, engaging environment that represents and supports cultural diversity and the different stages of child development.

• We encourage children’s sense of self, help with self-regulation and supports for conflict resolution and relationship building.

• When conflict arises, we support children by guiding them using High Scope’s six steps of conflict resolution. This develops a child’s social and emotional development by helping them understand their own feelings, as well as others’. It teaches them to identify, express and regulate their emotions appropriately. This builds relationships and supports positive interactions with others in group settings.

• We access Shine Early Learning Indiana for support, coaching and professional development. Those areas of support include but aren’t limited to professional development and training, inclusion specialists and early childhood guidelines.

• RKQ seeks family engagement and collaboration in a variety of ways. We conduct home visits, conferences, daily correspondences and regular communication. Those relationships foster success which may include child behavior and solution strategies used in the home or other settings.

• Referrals for challenging behaviors are conducted as necessary. We have access to supports to address challenging behaviors, early childhood mental health consultants, First Steps and preschool special education services through SBCSC. We will initiate and provide all supports reasonably possible to remedy concerns or challenges.

• Teaching staff is supported through embedded professional learning around implicit bias and distinguishing concerning behaviors from developmentally appropriate behaviors.

• Our administration collects and analyzes information on suspensions and expulsions that are occurring within our program and sets goals to limit or prohibit such disciplinary actions.

• Exclusionary processes are used a last resort. Exclusionary measures are taken when a serious safety threat exists and can’t be addressed with reasonable modifications and/or the use of positive behavioral supports.

• We believe staff, administration and families shall all actively participate in order to avoid expulsion.

• Challenging behaviors will be addressed as outlined here and documented. If said measures prove unsuccessful and/or behaviors are deemed as a threat, it is then that the expulsion of a child will occur. It is our intention to assist in accessing services and alternative placement to the best of our ability.

• Other means for expulsion includes parent negligence or inappropriate/disrespectful behaviors, delinquent payments and delinquent CCDF or OMWPK attendance verification.

I have read, understand and agree to the terms in this agreement. I understand my role and responsibilities to ensure my child’s enrollment at RKQ Learning Center.
Child's Name
Parent's Signature*

Clear
Date

MonthDayYear
Date

Should be Empty:

Raising Kings and Queens Application

Hours: