2023 DKZ Enrollment Form All Ages

NON-INGESTIBLE OVER THE COUNTER (OTC) MEDICATION AUTHORIZATION FORM

DISCOVERY KIDZONE
CHILD NAME*

First NameLast Name
DOB*

MonthDayYear
Date
TODAY'S DATE*

MonthDayYear
Date
I GIVE PERMISSION FOR THE FOLLOWING NON-INGESTIBLE OVER THE COUNTER MEDICATIONS (MARK ALL THAT APPLY)*

DIAPER RASH CREAMS/OINTMENTSINSECT REPELLENTSUNSCREENCORTISONE/ANTI-ITCH CREAMSBURN CREAMS/SPRAYSOTHER NON-INGESTIBLE OTC'S PLEASE SPECIFY BELOW
OTHER NON-INGESTIBLE OTC'S I GIVE PERMISSION FOR (THAT IS NOT LISTED ABOVE)
TO ADMINISTER A NON-INGESTIBLE OVER THE COUNTER (OTC) MEDICATION:
- THE OTC MEDICATION MUST BE BROUGHT TO THE FACILITY FROM THE PARENT
- THE OTC MEDICATION MUST BE IN ITS ORIGINAL CONTAINER, WITH A LEGIBLE LABLE, AND EXPIRATION DATE OF MEDICATION
- THE CHILD'S NAME MUST BE LEGIBLE AND ON THE ORIGINAL CONTAINER
SPECIAL HANDLING INSTRUCTIONS
REFRIGERATION REQUIRED

YESNO
Signature*

Clear
THIS DOCUMENT MUST BE UPDATED ON AN ANNUAL BASIS

Agreements
Parent Handbook

I acknowledge that I viewed the parent handbook in the parent corner on the website www.discoverykidzone.com/parent-corner I agree to abide by the policies set forth in the handbook.
Signature*

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Parents as Partners

I acknowledge that I viewed the parent as partners form in the parent corner on the website www.discoverykidzone.com/parent-corner I agree to abide by the policies set forth.
Signature*

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Emergency Closures

In the event of an emergency closure, utility outage, inclement weather closure, health department closure or government shutdown parents will be notified via phone, email or communication app. Should the center or your child's classroom need to close for any reason, tuition will not be refunded or reduced for closures of less than 14 school days.
Signature*

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Covid-19 Disclosure

I certify that I have read, understand and agree to comply with the Covid-19 provisions listed on the website in the parent corner www.discoverykidzone.com/parent-corner
Signature*

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Health and Illness

At Discovery Kidzone we understand that children will have stuffy noses and coughs at times. We do ask however, that if your child exhibits of the following symptoms that you please keep them home. Guardians agree to keep or take their child home within 45 min of being called to pick up. A late fee will be charged if picked up after 45 min. You agree to keep your child home until they are 24 hours after being symptom free. Here are the symptoms: Fever 100.1 or higher, Diarrhea (3 contained in diaper, 2 out of diaper/clothing), Vomiting, runny nose with green discharge, Rash that is suspicious, Discharge from eyes, Lice and nits, Communicable diseases (hand foot and mouth, chicken pox, covid-19, measles, mumps, influenza, RSV, norovirus etc.), Ring worm, impetigo, strep throat, whooping cough, croup, difficulty breathing. requiring one on one care, lethargic.
Signature*

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Outside Employment

I understand that the staff of this facility are prohibited in participating in outside employment with the parents unless approved and this includes babysitting.
Signature*

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Social Networking

I understand that the staff of this facility are prohibited in friending, following and participating in social networking activities with parents and children enrolled in this facility such as facebook, instagram, snapchat, pinterest, twitter, tik tok etc.)
Signature*

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Parent Orientation

This is your orientation checklist. This orientation list is intended to help you understand what you need to know when you leave your child in our care. If an area below isn’t covered please let your director know. · Tour of the facility· Check in/out procedures· Introduction to teachers· Late pick up fees· Tuition· Needs of the Child· Car Seat Policy· Non-Smoking policy· Phone free pick up and drop off· Procare invite· School Calendar· Menu· School Facebook page and Family facebook group· Ice Cream Social
Signature*

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Child imMTrax Permission Form
Child's Name*

First NameLast Name
Gender*

MaleFemale
DOB*

MonthDayYear
Date
Primary Health Care Provider*
I authorize my health care provider and a public health agency to collect and enter my child's immunization records into the Department of Health and Human Services' Immunization Information System (IIS). The IIS is a confidential, computer system the contains immunization records. I understand that information in the registry may be released to a public health agency as well as my health care providers to assist in my child's medical care and treatment. In addition, information may be released to child care facilities and schools in which my child is enrolled to comply with state immunization requirements. I understand that I can revoke this authorization and have my record removed at any time by contacting my local health department.
Signature*

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Tuition Express

We are excited to offer the safety, convenience and ease of Tuition Express- a payment processing system that allows on-time tuition and fee payments to be made from your bank or credit card. All credit and debit cards will have a 3% fee added. ACH transactions have no fee.
Electronic Funds Transfer Authorization

I hereby authorize Supalla Inc. DBA Discovery Kidzone to initiate charges to the below reference credit card or bank account. To properly affect the cancellation or change of this agreement I am required to give 14 days written notice.
Name of Primary Payer on this account

First NameLast Name
What payment method do you choose?*
Cash or Check?

CashCheck
Section A Credit Card or Debit Card 3% fee added

Please only fill out this section if you are using a credit or debit card
Card Holder Name

First NameLast Name
Account Number
Expiration Date

MonthDayYear
Date
Today's Date

MonthDayYear
Date
Signature

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Section B Bank Account (ACH) No fee added

Please only fill out this section if you are using your bank account for payments
Cardholder Name

First NameLast Name
Bank Name
Bank Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Type of Bank Account

CheckingSavings
Bank Routing Number (See sample Below)
Bank Account Number (See sample below)

Required Infant Forms 0-24 months
Infant Feeding Schedule

Must be updated every 60 days or when a child changes feeding schedule
Infant Name

First NameLast Name
DOB

MonthDayYear
Date
Parent Name

First NameLast Name
Type of Food Consumed

Breast MilkFormulaMilkSolid Food
Type of Formula
Type of Milk
Types of Solid Foods
Average Daily amount of breast milk
Average daily amount of formula
Average Daily amount of milk
Average daily amount of solid food
List approximate times that the infant eats, what the infant normally eats at each designated time and the approximate amount.
Time infant eats and what type Breast Milk, Formula, Milk, solid food
Pediatric Health Statement Please send the link below to your child's doctor to fill out.

https://form.jotform.com/212236619269056

Special Needs and Behavioral Needs Health Care Plan

This form is required if your child has allergies, special needs or behavioral needs
Child's Name

First NameLast Name
DOB

MonthDayYear
Date
Parent Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Primary Health Care Provider

First NameLast Name
Primary Health Care provider number
Please enter a valid phone number.
Specialty Doctor

First NameLast Name
Specialty Doctor Number
Please enter a valid phone number.
Therapist Name

First NameLast Name
Therapist Number
Please enter a valid phone number.
Diagnosis (s)
Allergies
Behavioral
Routine Care
Medication to be given at Childcare. Schedule when and how much, How to administer, Reason Prescribed, Possible side effects
List of medications given at home
Needed accommodations
Diet or Feeding
Classroom Activities
Schedule accommodations
Modified environment accommodations
Therapy Schedule and where it will take place
Naptime/Sleeping accommodations
Toileting accommodations
Outdoor or Field trip accommodations
Transportation accommodations
Behavior changes steps and tips to redirect
Additional Comments
Special Needs Equipment/Food Supplies/Medical Supplies
1.
2
3
Allergy Instructions for Staff
What is specific allergy
What symptoms to look for
Steps to follow if we suspect an allergy outbreak
Emergency Care
Call Parents first then Who?
Call 911 when?
Take these measures while waiting for parents or medical help to arrive
Suggested Special Training for Staff
Optional Parent Notes
Signature I hereby give consent for my child's health provider, specialist or therapist to communicate with my child care provider to discuss any of the information contained in this care plan.

Clear
Should be Empty:

Enrollment Form

Child's Information

Parent/Guardian Information

Parent Guardian 2 Information

Authorized Child Pick Up and Emergency Contacts

Written Consent is Given For:

Health History

NON-INGESTIBLE OVER THE COUNTER (OTC) MEDICATION AUTHORIZATION FORM

Attendance

School age Attendance during school year for grades K-5

Permissions

Photo Release

Agreements

Parent Handbook

Parents as Partners

Emergency Closures

Covid-19 Disclosure

Health and Illness

Outside Employment

Social Networking

Parent Orientation

Child imMTrax Permission Form

Tuition Agreement

Tuition Rates

Tuition Express

Section A Credit Card or Debit Card 3% fee added

Section B Bank Account (ACH) No fee added

Child Biography

Developmental History

Family Information

Comforting

Daily Schedule

Bottle/Cup Routine

Solid Foods

Required Infant Forms 0-24 months

Infant Feeding Schedule

Pediatric Health Statement Please send the link below to your child's doctor to fill out.

Special Needs and Behavioral Needs Health Care Plan

Routine Care

Needed accommodations

Special Needs Equipment/Food Supplies/Medical Supplies

Allergy Instructions for Staff

Emergency Care