The Love Bug Music & SLS Club

EMERGENCY CONTACTS (Others that may be reached, if we cannot reach you.)
Emergency Contact #1 Name
Home
Work
Cell
Emergency Contact #2 Name
Home
Work
Cell
Emergency Contact #3 Name
Home
Work
Cell
Doctor's Name
Phone
Health Insurance Co.
Policy Number
Allergies
Medications
Special Needs
(Anything we should know about your child to ensure he/she has a good camp experience, private meetings with Director available upon request People authorized to pick up child
People authorized to pick up your child #1*
People authorized to pick up your child #2
People authorized to pick up your child #3
People NOT authorized to pick up your child #1
People NOT authorized to pick up your child #2
People NOT authorized to pick up your child #3

Student's Personal Information
Please describe your child's Special Needs
Please describe any triggers and what makes your child happy.
When upset, what behavior does your child display?
What calms your child down?
Allergies
Additional Details (Please Share Information Regarding Behaviors and Mannerisms)

PLEASE READ CAREFULLY

We do not provide transportation from school at this time; however, Columbia County School buses will drop off your Love Bug at our location. Contact your Love Bug's Teacher to change the drop-off location to 106 SRP Drive Evans GA 30809 Suite A or regular drop is welcome. Please let us know how your Love Bug will arrive.

Unfortunately, due to pre-planned events and scheduled staffing, we are unable to issue any refunds for days missed. 7-day advance notification is required for preplanned absences. If your child misses a week(s) without advance notification, full tuition for the weeks missed and the current week MUST be paid to return. Weekly tuition is due every Monday, one week ahead. A $25 late fee will be automatically charged the day after payments are due. The NON-REFUNDABLE registration fee is $50 per child. This ensures your child a spot. If this fee is not paid when the application is submitted, placement is not guaranteed, and your child may end up on our waitlist.

Pricing is reevaluated semi-annually. It is our goal to keep the cost as low as possible while offering an excellent, quality-rated experience. The cost is $150 per week, 3PM-6PM. Weekly tuition includes all activities, onsite entertainment, afternoon snacks, and special treats. The cost is $200 per week (3 pm-6 pm) for ALL NON-POTTY TRAINED AND MEDICALLY COMPLEX ATTENDEES THAT REQUIRE INDIVIDUALIZED CARE. While registration is allowed for non-potty trained and medically complex attendees, final approval is required. Your application will be reviewed, and you will be contacted by the Director for a phone/in-person conference. Late pick-up will result in a $25 per hour fee. At 6:15 PM, a late fee will be charged.

By signing this document, I verify that I have read through the 2022-2023 Love & Care Exceptional Children's Aftercare packet in its entirety. I verify that I have thoroughly read the policies, pricing, due dates, and scheduled hours. I understand that submission of this form AND payment of the registration fee is reserving my child a spot, if still available, or a spot on the waitlist if all slots have been filled before my submission. Details regarding the program will be sent after registration is complete.
Parent/Guardian Signature*

Clear
Date

MonthDayYear
Date
As the parent/guardian of the listed child, I authorize my child to participate in all activities. I permit Love & Care Exceptional Children’s Childcare LLC., to administer first aid, and in the event of an emergency, to secure a physician for any emergency treatment needed for my child. I understand that a conscious effort will be made to locate me or a close relative before any action is taken. I understand and accept that this expense is my responsibility. I also understand that it is my responsibility to carry primary accident and health insurance.
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date
Photography Release
I understand that photos may be taken and used for websites, social media, and promotional purposes. If I object, I have marked the * no photos/no videos option below.

I prefer that no photos or videos be used.
Parent/Guardian Signature*

Clear
Date

MonthDayYear
Date

Notice of No Liability and Acknowledge

I understand that I am being informed in writing, by signing this acknowledgment that this facility does NOT carry liability insurance to protect my child in the event of Covid-19, injuries, illnesses, accidents, etc. Love & Care Exceptional Children's Childcare LLC., Love & Care Exceptional Children's Summer Camp LLC., Love & Care Exceptional Children's Love Bug Music Club, The T.Y.L.E.R Movement, or any of its other affiliates are NOT responsible for injuries, illnesses, accidents, medical costs, lost wages, etc.
Signature*

Clear
Date

MonthDayYear
Date
Bright From the Start Exemption Acknowledgement

This acknowledgment serves as a notice, that Love & Care Exceptional Children’s Childcare LLC., is NOT a licensed daycare facility. I understand that this program is not required to be licensed by the Georgia Department of Early Care and Learning and is exempt from state license requirements. Please sign below as an acknowledgment that you have received this notice.
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date
Please read and initial the following statements:
Type a label*   There is a $100 fee charged for ALL returned checks.
Type a label*   No pro-rating, one day is considered a full week. NO REFUNDS.
Type a label* I received my parent handbook and understand that all rules are contained in it.

Intervention Behaviors (Verbal and/or Written Notification): This notification is only so that we can work together as a team, to reduce certain behaviors.
- Excessive screaming
- Sensory overload
- Perseverative behaviors that interfere with the class such as noises or singing
- Running away from staff (That puts themselves in danger)
Behaviors that Require a Parent Pick-Up: Behavior that continues even after interventions have been tried and affects the safety of the child, other children, and/or staff. Some of these behaviors may include intervention behaviors listed above, as well as:
- Self-injurious behaviors
- Fighting with another student or staff member
- Inappropriate language
- Continuous non-compliance
- Spitting and/or intentionally using bodily fluids to be defiant
- Aggressive behaviors
Expulsion Behaviors: ALL Behaviors listed above, as well as:
- Repeated behaviors that require a parent pick-up and have not responded to
- Multiple interventions
**Aggressive behaviors towards Staff or fellow Consumers are grounds for expulsion. The program facility reserves the right to add to or change this list at any time*** Parents please be sure that you have read and understand the behavior policy. Any time an attendee is exhibiting behaviors that could injure themselves, staff, or other attendees or damage the program facility or community property, Staff will call them for the attendee to be picked up. Please understand that Love & Care Exceptional Children’s Childcare LLC. is not staffed to regulate severe behavior needs, as we are not a Behavioral Clinic or Therapy Center.
Does your child have a behavior plan? *
I have read the attached copy of the behavior policy. I understand and agree with the behavior policy at Love & Care Exceptional Children’s Childcare LLC.
Parent/Guardian Signature*

Clear
Date

MonthDayYear
Date
Should be Empty:

Please read and initial the following statements: