Application

Childcare Enrollment Application

Parents, to protect and promote the health and safety of your child, please supply a complete response to every item on this form. This information is required by the Mississippi State Department of Health, and our Child Care Licensure Inspector. If the item is not applicable, then please answer with N/A. Do NOT leave anything blank.
Child's Name:*

First NameLast Name
Date of Birth:*

MonthDayYear
Date
Home Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:*
Please enter a valid phone number.

Mother's Name:*

First NameLast Name
Place of Employment:
Work Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Work Number:
Please enter a valid phone number.
Mobile Number:*
Please enter a valid phone number.
Email:
example@example.com
Father's Name:*

First NameLast Name
Place of Employment:
Work Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Work Number:
Please enter a valid phone number.
Mobile Number:*
Please enter a valid phone number.
Email:
example@example.com

Read and initial the following to acknowledge receipt of these items:
I have been informed that Johnson's Nursery School & Daycare does NOT provide liability insurance for my child. (liability clause can be found on page 9):*
I have been given a copy of and have read the MSDH Regulation Summary for Parents. (can be found at the end of application):*
I have been given and have read and understand the facility's Parent Handbook (can be found on website as PDF):*
Complete 121 Immunization Compliance Form is on file at the facility before child attends. For Office Use Only

YesNo

In case of emergency and the PARENTS cannot be reached, contact the following:
Name:*

First NameLast Name
Phone:*
Please enter a valid phone number.
Relationship:*
Name:*

First NameLast Name
Phone:*
Please enter a valid phone number.
Relationship:*
Name:*

First NameLast Name
Phone:*
Please enter a valid phone number.
Relationship:*

The following people are authorized to pick up and drop off my child/children.

Please include all names. Calls/texts for add ons will not be allowed.
Name:*

First NameLast Name
Name:*

First NameLast Name
Name:*

First NameLast Name
Name:*

First NameLast Name
Name:*

First NameLast Name
Name:*

First NameLast Name

Complete each of the following sections by choosing yes or no:
My child may be photographed at the child care center.*
My child may take approved field trips sponsored by the center.*
The center may obtain emergency medical treatment for my child if needed.*
My child is potty trained.*
If no, a consultation between the parent and caregiver is required to be documented prior to potty training and kept on file. Date of consultation:
My child will eat breakfast at the center.*
If no, my child will eat BEFORE coming into the center.
Parent Signature:*
Date:*
Director Signature:
Date:
Record to be updated and signed by parent if NO changes (once a year):
Signature:
Date:
Signature:
Date:
Signature:
Date:
DIRECTOR USE ONLY: Enrollment Date: ____/_____/_____ Start Date: ____/_____/_____ Withdrawal: ____/____/____

Johnson's Nursery School/Daycare

7:00 a.m. - 5:00 p.m.
- Registration fee is $50 paid in advance.
- Tuition is paid in advance weekly or monthly. Tuition is due during presence or absence. NO CHECKS
- Fees for all late pickups are $3.00 per every minute after closing time. Tardiness more than three (3) times a month will result in termination of services.
- All fees must be kept in advance.
- Tuition is due on Monday unless due to absentees or holidays.
- 2 week notice prior to withdrawal is required.
- In the event of absences, tardiness or new arrangements in transportation, please call the center before 9:00 a.m.
MISSISSIPPI DEPARTMENT OF HUMAN SERVICE CHILD CARE CERTIFICATE PROGRAM
- Registration fee is $50 paid in advance.
- Copayments, if any, are due at the beginning of each month. NO CHECKS
- 2 week notice required prior to withdrawal.
- In the event of absences or new arrangements in transportation, please inform the center beforehand.
- Mandatory sign in and sign out of students on roster.
- $3 per minute late fees for pickups made after closing time are the responsibility of the parent and are not covered by the certificate program.
Signature:*
Date:*
Witness:
Date:

Daycare Liability Insurance Ages 1-5

Under the closest supervision, accidents still occur, especially with small children. Due to this being a known fact, Johnson's Daycare does not carry the form of liability insurance that will cover daycare center accidents.

In the event that your child, not due to neglect, is injured (choking, falling, SIDS, etc.), needing professional medical attention, Johnson's Daycare will provide adequate transportation to the closest medical facility, being Madison River Oaks Medical Center. Proper parental notification will be made before and after transportation (pending the time and nature of the accident) to the medical facility. All medical expenses are of sole responsibility of the parent or guardian.

Not only does this relinquish Johnson's Daycare from liability of child related accidents, but any person transporting your child to or from this facility should be aware that you, the parent of the child being transported, are financially responsible for any accidents he or she, the transporting party, may encounter while on Johnson's Daycare premises.

Signing this statement means that you, the parent have read, understand, and relinquish Johnson's Daycare from any liability due to any accident(s) (not due to neglect) that may occur in this center or on the premises. Also this is an authorized consent form to transport your child to Madison River Oaks Medical Center, to receive any necessary medical treatment.
Child's Name:*
Signature:*
Date:*
Witness:
Permission to Release Photograph

I give permission to Johnson's Daycare to appropriately use images/recordings of my child for business uses, such as social media, website, brochures, banners, etc.
YesNo
Child's Name:*
Signature:*
Date:*

SUPPLY LIST

Toddlers (Ages 1 & 2)

Diapers/Pullups

Wipes

2 Boxes of Kleenex

2 Rolls of Paper Towel

2 Handsoaps

2 Sanitizers

2 Large Bibs

Change of Clothes

2 Large Blankets (NO SLEEPING BAGS)

Small Pillow (NO SLEEPING BAGS)

Red & blue Nap Mat (NO SLEEPING BAGS)

Jumbo Crayons

Crayon Box

No Sippy Cups/Bottles

NO OUTSIDE FOOD OR DRINKS ALLOWED

Uniform is mandatory Monday-Thursday of the regular school year and consists of burgundy/maroon or white tops and khaki bottoms. NO EXCEPTIONS. Failure to comply will result in a $15/day penalty.

Preschool (Ages 3-5)

2 Jumbo Pencils

2 Glue Sticks

2 Large Boxes of Kleenex

2 Rolls of Paper Towel

2 Liquid Soaps

2 Sanitizers

1 Preschool Handwriting Tablet

1 Pack of Wipes

Coloring Book

2 Blankets for Nap (NO SLEEPING BAGS)

Small Pillow (NO SLEEPING BAGS)

Red and blue Nap Mat (NO SLEEPING BAGS)

Change of Clothes

2 Large Bibs - Optional

Large Crayons (No Jumbo or Small)

Crayon Box

NO OUTSIDE FOOD OR DRINKS ALLOWED

Uniform is mandatory Monday-Thursday of the regular school year and consists of burgundy/maroon or white tops and khaki bottoms. NO EXCEPTIONS. Failure to comply will result in a $15/day penalty.

TUITION:

Registration: $50

7:00 a.m. - 5:00 p.m.

Toddlers

Age 1 -$145

Age 2 - $140

Preschool

Ages 3-5 - $135

Non Potty Trained Fee $30/week

Childcare vouchers are accepted.

Cashapp - $johnsonsdaycare613 (tuition/copays only)

Any fees accrued must be paid in cash.

DOWNLOAD HANDBOOK AT

jnskids.wix.com/johnsonsdaycare
Should be Empty:

Childcare Enrollment Application

Read and initial the following to acknowledge receipt of these items:

In case of emergency and the PARENTS cannot be reached, contact the following:

The following people are authorized to pick up and drop off my child/children.

Complete each of the following sections by choosing yes or no: