Childcare Intake

Agape Childcare and Learning Center
First Name*
Last Name*
MI
Age*
Birthdate*

MonthDayYear
Date
Address*
City*
State*
Zip*
Parent/Guardian 1
Name*
Work phone
Email*
example@example.com
Home phone*
Occupation
Parent/Guardian 2
Name*
Work phone
Email*
example@example.com
Home phone*
Occupation

Emergency Contact Person 1
Name*
Relationship*
Phone number*
Emergency Contact Person 2
Name*
Relationship*
Phone number*

Supplies (infants ONLY)
Is your child an infant?*
Formula
Pampers
Baby Wipes
Cereal

Developmental Milestones
Any birth complications (if yes, explain)?*
Has your child been cared for by anyone other than parents?*
Has your child previously attended other than parents?*
Does your child use the restroom independently?*
Does your child need help dressing and undressing?*
Does your child take a nap?*
Does your child have any special fears?*
Does your child dislike any particular foods? Please list
Does your child have a history of physical impairment(s)? Please list

Child Interest
Favorite games
Favorite toys
Favorite books
CHANGE OF CLOTHES AT LEAST 3 DIFFERENT PAIR, ALONG WITH SOCK AND SHOES (CHANGE OF CLOTHING MUST BE CHECKED EVERY MONTH FOR SIZE) (PANTS, T-SHIRT AND SHIRT)
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date

Arrival and Departure Information
My child will arrive at the Agape Childcare and Learning Center, Monday through Friday, at?*
My child will depart at the Agape Childcare and Learning Center, Monday through Friday, at?*
If there are any days in which your child will not attend the Center Please Call The

Center to inform US of the child absence.
My child will be picked up by the following (Please list name, number and relationship the child)*
ALL PICKUP PEOPLE MUST BE AT LEAST 17 YEARS OF AGE, KNOW THE CHILD

AND MUST SHOW THEIR PICK UP CARD BEFORE THE CHILD CAN BE RELEASED TO THEM.

*******If someone other than the people named above will pickup the child please call the Center and give the appropriate information. If not the child will not be released to that person*******

Any addition cards will be $5.00 per card.

P.S. THE PERSON WILL NEED STATE ISSUED ID
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date

Medical Authorization
I, the undersigned, who states that I am the parent or legal guardian of Full Name who is Type a label hereby authorize Agape Childcare and Learning Center and its designated representative to secure the necessary medical, hospital, or surgical attention in the event of illness or injury to my child.

I understand that I will be responsible for All Medical Bills. Agape Childcare and Learning Center assumes NO responsibility for Medical Care or Any Medical Bills of illness or injury to participants in the Center other than licensed Day Care. I am also giving consent in extreme emergency or take whatever action necessary for the well-being of my child.
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date
Home phone*
Parent/Guardian 1
Work phone
Parent/Guardian 2
Work phone

Prescription Medication
If we are to administer medication to your child, it must be in the Doctors prescribed bottle with the pharmacy label. If the bottle does not have the label then we can not

administer the medication. We will also need a note from the Doctor on how much to

give and how many doses during the day. Please adhere to all of these terms. They are very important when it comes to the safety of your child.

if for some reason you do not understand or need more clarification please see the

Executive Director or Assistant Director.
Current prescribed medication?*
Doctor*
Doctor's Phone #*
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date

Emergency Health Card
Date*

MonthDayYear
Date
Name*

First NameLast Name
Birthdate*

MonthDayYear
Date
Address*
City*
State*
Zip*
Home Phone Number*
Clinical or Hospital*
Physician's Name*
Clinical or Hospital Address*
Clinical or Hospital Telephone number*
Does your child have any medical condition which need special attention from us (Please list)?
Allergies to any Medications or Foods (Please list)?
First Emergency Contact
Name*
Phone*
Second Emergency Contact
Name*
Phone*

Parental Consent Form
In Case of Sickness or Accident, I hereby give Parental Consent to Agape Childcare and Learning Center to secure Emergency Medical Care through for my child.

I UNDERSTAND I WILL BE RESPONSIBLE FOR ALL MEDICAL BILLS.
TRIP RELEASE*
I hereby give consent for my child to participate in, walking trips, special excursions to places of interest. The use of Public Park Facilities and other field trips sponsored by Agape Childcare and Learning Center.
SWIMMING & P.E. RELEASE*
I hereby give consent for my child to participate in, walking trips, special excursions to places of interest. The use of Public Park Facilities and other field trips sponsored by Agape Childcare and Learning Center.
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date

Photo Release for Marketing and Advertisement
When taking photographic or video images that are intended for promotional use by Agape Child Care Learning Center, releases should be obtained from subjects who will be recognizable. This procedure applies to images to be used in printed publications, displays, videotapes, on Agape Child Care Learning Center's website, and in any other formats. By signing this statement, you agree for Agape Child Care Learning Center to use your child's photo/video for marketing, advertisement on social media platforms such as Agape Child Care Learnings Center Facebook @agapechildlearning, Instagram (coming soon), Twitter (coming soon) and any other forms of social media.
I, Your Name , parent/guardian of Child's Name authorize Agape Child Care Learning Center to use my child's, photo, video, name (first name only) statements and likeness, without charge, for promotional, marketing and advertisement purposes in Agape Child Care Learning Center publications, advertising, video, web, new media, or other formats as listed above.
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date

Fees Form
First Name*
Last Name*
MI*
Birthdate*

MonthDayYear
Date
Room #
Fees
Annual Registration fee $50

*****REGISTRATION FEE PLUS FIRST WEEK OF CHILDCARE IS DUE AT THE SIGNING OF THESE DOCUMENTS*****
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date

DISCIPLINE AND GUIDANCE POLICY
I have read and understood that the following behavior is prohibited, at Agape' Child Care Learning Center.
1. Corporal Punishment, including hitting, spanking, swatting, beating shaking, pinching and other measures intended to induce physical pain or fear.
2. Threatened or actual withdrawal of food rest or use of the bathroom.
3. Abusive or profane language.
4. Any form of public or private humiliation, including threats of physical punishment.
5. Any form of emotional abuse, including shaming, rejecting, terrorizing, or isolating a child.
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date

INTEGRATED PEST POLICY
Agape' Child Care Learning Center strongly advocates the use of Integrated Pest Management (IPM IPM is an environmentally sensitive approach to pest management that relies on a combination of common sense practices. PM programs use current, comprehensive information on the life cycles of pests and their interactions with the environment.

Pest populations can be prevented or controlled by creating inhospitable environments by removing some of the basic elements pests need to survive, or by blocking their access into structures. Pests may be managed by other methods such as traps, vacuums or pesticides. Maintenance and sanitation is only completed when children are not in day care (the weekend only).

As IPM program consists of a cycle of routine inspection and accurate identification of pests are vital steps in IPM to insure control methods will be effective.
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date

BITING POLICY FOR ALL AGE CHILDREN
Effective immediately upon enrollment. Agape' Child Care Learning Center has established policy for children who bite. This policy exist due to an increased number of biting incidents with children in centers and schools. The following policy will be highly enforced if your child bites any other child in the center:
- If a child is hurt due a to a biting incident, that child will receive first aid from the center if it is a minor injury. If the skin is broken and the staff feels that the child needs medical care 911 will be called.
- The parents of both children will be called immediately.
Agape' Child Care Learning Center is here to protect the children and their safety. All children deserve the righto feel safe in their own environment. Being bitten can be extremely painful as well as detrimental to a child's heath. This rule will be highly enforced.

Again we want our parents to be aware that children will bite, however it is our duty to protect all children. And for you as parents to feel comfortable and safe.

Expectations for Child's Behvaior
Agape' Child Care Learning Center has established an acceptable method of guiding the behavior of children for their protection and growth. These guidelines will be administered in a way that will help each child develop self-control and assume responsibility for his or her actions through clear and consistent rules and limits appropriate to the ages and development of children in care. The staff uses acceptable techniques and include, but are not limited to redirecting a child to an alternate activity, rewarding acceptable behavior, encouraging children to talk about their feelings and providing any example for children by speaking and interacting with children in a positive manner. The Center will discipline in the following manner:
1. The staff will first talk to the child about their behavior.
2. The staff will redirect the child.
3. Time out will be 1 minute for the age of the child.
4. As a last resort, the child will be sent to the office until his/her behavior is under control.
5. If after exhausting all of the above possibilities, the child's disruptive behavior continues and his behavior puts other children in danger, the parents will receive one warning that they must get their child under control, or the child will no longer be able to be registered or attend Agape' Child Care Learning Center.
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Agape Childcare and Learning Center

Parent/Guardian 1

Parent/Guardian 2

Emergency Contact Person 1

Emergency Contact Person 2

Supplies (infants ONLY)

Developmental Milestones

Child Interest

Arrival and Departure Information

Medical Authorization

Prescription Medication

Emergency Health Card

Parental Consent Form

TRIP RELEASE*

SWIMMING & P.E. RELEASE*

Photo Release for Marketing and Advertisement

Fees Form

DISCIPLINE AND GUIDANCE POLICY

INTEGRATED PEST POLICY

BITING POLICY FOR ALL AGE CHILDREN

Expectations for Child's Behvaior