CALVARY CHILDREN'S LEARNING CENTER DAYCARE APPLICATION

CALVARY CHILDREN'S LEARNING CENTER BEFORE AND AFTERCARE APPLICATION 2023-2024
STUDENT'S INFORMATION
Student's Name:

First NameLast Name
Age*
Grade of Student
School Start Time*
School End Time*
Early Dismissal*
Name of School*
School Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
School Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian's Cell
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian's Email
example@example.com

Student's Information
Student's Full Name*

First NameLast Name
Date of Birth*
Age*
Ethnicity*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Please Select One*
Is your child a returning student ?*
Current School*
Current Grade*
Preferred Start Date*

MonthDayYear
Date

Parent's Information
Father's Name*

First NameLast Name
Occupation*
Employer*
Work Hours*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Work Number*
Please enter a valid phone number.Format: (000) 000-0000.
Cell Number*
Please enter a valid phone number.Format: (000) 000-0000.
Parent's Email*
example@example.com
Mother's Name*

First NameLast Name
Occupation*
Employer*
Work Hours*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Work Number*
Please enter a valid phone number.Format: (000) 000-0000.
Cell Number*
Please enter a valid phone number.Format: (000) 000-0000.
Parent's Email*
example@example.com
Address (if different from applicant)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Person/Persons authorized to pick-up my child at the end of each day or in the event of an emergency. (Please include phone numbers for each person)*
YESNO
If yes, please attach a copy of the Court Order to keep on file at Calvary Children's Learning Center (CCLC). Please explain any social or family circumstances of which CCLC should be aware.
File Upload

Cancelof

Medical Information

Health Information: Please submit immunization record before the 1st (first) day of school. By state law ALL students must have physicals completed by this day.
List any specific medicals conditions or behavioral problems
List any social or emotional concerns
Are there any conditions. or specific needs that require special attention?
List any food(s) or liquids that should be omitted from your child's diet*
YESNO
If yes, please list

Medication:
Primary Care Doctor*
Primary Care Doctor Phone # *
Child's Insurance Company*
Please pack all medication in a sealed container, clearly labeled with your child's name, age, name of medication, dosage and time. Please deliver to the Director for the week.
Medication #1
Medication #1 Time
Please put the time this medication must be administered to your child
Medication #1 Dosage
Medication #2
Medication #2 Time
Please put the time this medication must be administered to your child
Medication #2 Dosage
Medication #3
Medication #3 Time
Medication #3 Dosage
List all sensitivities and/or reactions to drugs, food, etc. Please write "None" or "N/A" if no allergies exist*
Any medical conditions or special needs )i.e. asthma, RAD, reflux, food intolerance, peanut allergies, etc.) Please list all:*
I will send foodSubstitute a cheese or peanut butter sandwich
An initial registration fee of $25.00 (Twenty-Five Dollars) shall be paid for each child at the time of enrollment, renewed each year thereafter. The registration fee shall be due upon registration or the first day of school. All fees are non-refundable. We accept Cash or Money Orders only. WE DO NOT ACCEPT PERSONAL CHECKS

If your child is not picked up on time a fee of $10.00 (Ten Dollars)every 10 (ten) minutes will be incurred for each child. Payment of all fees is due immediately (same day).

Weekly fees are due on the Monday morning of the current week. NO
EXCEPTIONS.

If there is a balance brought forward, an automatic fee of $25.00 will be applied. If for any reason an account becomes delinquent (over one-week past due without receipt of payment),an extra 20% charge applied along with an additional charge of $25.00. The child will alsobe withdrawn from school attendance records until payment is paid in full.

If payment arrangements are not made to settle delinquent account, Calvary’s Children’sLearning Center reserves the right to dismiss the child, and the parent shall remainresponsible for the balance due including any expenses incurred by Calvary’s Children’sLearning Center in the pursuit of payment.

Withdrawal: The obligation for full payment of fees will continue until the date indicated
by the parent as to the withdrawal date of the child. If the parent fails to provide written
notification the child’s withdrawal from the school, the parent shall remain responsible for
full payment of tuition (remaining months of school year) after the child’s last day of
attendance plus all late charges or penalties, which shall accrue until full payment is
received.
Parent's Signature
PERMISSION:
I hereby grant Calvary’s Children Learning Center permission for my child to:

A. Take part in all program activities including, but not limited to, the use of indoor
and/or outdoor equipment.

B. Be photographed and/or videotaped in connection with the daily program activities.

C. Leave the premises of Calvary’s Children Learning Center to take part in planned field
trips supervised by Calvary’s Children Learning Center staff. Parents are encouraged
to participate in field trips when available.

D. Participate in water-related activities supervised by Calvary’s Children Learning
Center staff.

HANDBOOK:
Each parent is responsible for reading the Calvary’s Children Learning Center Parent
Handbook. Signature on this Application acknowledges receipt of, understanding of, andadherence to all polices stated in the Parent Handbook, and any Addendum (which may be in the form of a memo).

We have specifically reviewed each of the provisions of this Application and Parent
Handbook and hereby agree to comply with all provisions hereof.

As parent/guardian of the student(s), I attest that the information above is true and accurate

to the best of knowledge. If the Applicant is accepted to Calvary’s Children’s Learning
Center, I give my permission to the Calvary Children’s Learning Center’s Executive
Director/Director/Staff/Volunteer to secure medical attention as needed in the case of anemergency. I also waive any and all liabilities of the Calvary’s Children’s Learning Center Executive Director/Director/Staff/Volunteer or Calvary Baptist Church or its
representatives.
Parent's Signature
Date

MonthDayYear
Date
CALVARY CHILDREN’S LEARNING CENTER (CCLC)

AGREEMENT – 2022-2023

I, {Parent's Name} as the parent/guardian for, {Child's Name}a minor child who is in my care and Custody, do hereby grant my permission for my child to attend a program or event at Calvary’s Children’s Learning Center (“CCLC”). I fully understand the nature of camping and recreational activities associated with the use of CCLC’s facilities and/or programs
includes an inherent risk of danger, which may result in personal injury or harm to my child. I understand that my child will be under adult supervision at all times but, notwithstanding any level or degree of supervision, that accidents may occur which may result in physical injury or harm to my child. It is with the full understanding of the risks associated with these types of activities that I grant permission for my child to participate in the program to be conducted at CCLC. I agree to indemnify and hold harmless CCLC, it’s Executive Director, Director, Employees, Agents and/or Representatives from any claim for nay injury or damage, which may result from my child’s attendance and participation. I understand that by signing this Agreement, I am voluntarily and knowingly accepting responsibility for my child’s participation in the activity or program to be conducted at CCLC. I also grant permission for pictures and images of my child to be taken while participating in activities and used for CCLC.

Dated this day {date}.
Parent's Signature

RULES & REGULATIONS

Please read and discuss the below Rules & Regulations with yourchild and have him/her sign the contract:
1. I will be respectful to others at all times.

2. I will not use profanity.

3. I understand that no horseplay is allowed.

4. I will stay with the assigned team and team leader.

5. I understand that my Parent/Guardian may be called to pick me up for
continuous disruptive behavior.

6. There is to be at any time absolutely No TOUCHING. NO KICKING, NO
HITTING, NO SPITTING, NO FIGHTING, NO SHOVING, NO
DISRESPECTING ANY ADULTS OR CLASSMATES AND NO
INAPPROPRIATE TOUCHING

7. NO chewing of gum at any time.

8. There will be NO food or drinks allowed except during lunch and snack
time.

9. Please call to notify the Learning Center if your child:
Will arrive later in the day, is going to be absent, or needs to leave early.
Children who arrive after 9:30 AM will not be admitted unless they have a
doctor’s note.

10. All of the above could be cause for dismissal.
Child's Signature
By: CCLC Management
Should be Empty:

CALVARY CHILDREN'S LEARNING CENTER BEFORE AND AFTERCARE APPLICATION 2023-2024

STUDENT'S INFORMATION

Student's Information

Parent's Information

Medical Information

Medication:

RULES & REGULATIONS