WeVillage Sherman Oaks Child Registration Form

Welcome to the WeVillage Sherman Oaks Child Registration Process

One Child Per Registration
TO ALL OF OUR PROSPECTIVE CLIENTS: We are delighted to have you enroll your child with WeVillage. We want to let you know up front that, due to state and federal childcare regulations and form requirements, this enrollment form is a bit long. Please hang in there with us as our thoroughness helps us to take the best all around care of your child.

PLEASE ALSO NOTE: Please be prepared to upload a copy of your child's immunization records during this process.

Thank you.

BEFORE WE BEGIN . . .
Today's Date:*

MonthDayYear
Date
Name of Parent/Guardian Completing this Enrollment Form:*

First NameLast Name
Relationship to Child:*
Cell Phone Number:
Please enter a valid phone number.
Email*
example@example.com
PLEASE NOTE THE FOLLOWING BEFORE YOU BEGIN TO COMPLETE THIS FORM:

All fields marked with a red "*" are required and you must fill something in.

Accordingly, throughout this form, please enter "N/A" to any question to which you do not have a response or the question does not apply to your child. This will allow you to move forward to the next question.

To make this process easier for you, we have taken the liberty of pre-populating duplicate questions with some of your answers. However, in certain cases, the information may not be accurate. Please review all pre-populated responses and where the information is not accurate, please simply delete the pre-populated responses and enter in the correct information.

Thank you.
ONE LAST THING . . . We would love to know how you heard about WeVillage.
Please select any of the following that apply:

FriendFamily MemberReferral by current WeVillage attendeeInternet Search/WeVillage WebsiteFacebookInstagramOther
Name of Referral Source:*

First NameLast Name
If Other, please explain:*

CONSENT TO PROCEED ELECTRONICALLY
Before WeVillage Ventura, LLC can accept your electronic signatures for enrollment and medical information, you should be aware of, and affirmatively agree to, the following information:

- If I proceed, I am agreeing to complete this enrollment process electronically.

- My responses to all questions throughout the electronic process will be recorded and made a part of my child's records with WeVillage.

- I agree that my electronic signature is the equivalent of a manual signature and that WeVillage may rely on it as such in connection with any and all agreements I may enter into with WeVillage.

- I acknowledge and agree that it is my obligation to immediately advise WeVillage in the event that I withdraw my consent to use electronic means to sign WeVillage documents and agreements by sending an email with my withdrawal request to WeVillage.

- I agree that in the event that I decide to withdraw my consent, any document electronically signed prior to WeVillage receiving notification of my withdrawal will be considered validly executed and the withdrawal of my consent does not apply retroactively.

- I acknowledge and agree that the individual completing this Consent to Proceed Electronically is the individual whose name is typed below and that my typed name will be recorded as my electronic signature and will be relied upon by WeVillage to the same extent as if I had signed this consent in ink.

I agree to the above terms and conditions.
Signature of Parent/Guardian:*

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Name of Signer:*

First NameLast Name
Date Signed:*

MonthDayYear
Date

CHILD'S INFORMATOIN
Child's Name:*

First NameLast Name
Child's Gender:*

MaleFemaleOther
Child's Birthdate:*

MonthDayYear
Date
IF YOU WISH TO ENROLL A SECOND CHILD WITH WEVILLAGE . . .

Additional children must be enrolled separately. We know that this is time consuming up front, but the following forms can only be completed for the child named above. We are required to follow strict state and federal regulations for child care centers and we firmly believe that doing so is in the best interests of your children. The more information we have about the children enrolled at WeVillage, the better armed we are to respond to any kind of situation, provide the necessary information to emergency personnel, and make the contacts that you have provided to us.

Thank you for your understanding.

MOTHER'S INFORMATOIN
Mother's/Stepmother's/Guardian's - Marital Status:*

SingleMarriedDivorcedWidowed
Mother's/Stepmother's/Guardian's Name:*

First NameLast Name
Mother's/Stepmother's/Guardian's Address:*
Mother's/Stepmother's/Guardian's - Cell Phone:*
Please enter a valid phone number.
Mother's/Stepmother's/Guardian's - Home Phone:
Please enter a valid phone number.
Mother's/Stepmother's/Guardian's - Personal Email Address:
Mother's/Stepmother's/Guardian's - Employer's Name:
Mother's/Stepmother's/Guardian's - Work Phone:
Please enter a valid phone number.
Mother's/Stepmother's/Guardian's - Work Email:
example@example.com
Mother's/Stepmother's/Guardian's - Work Days:
Mother's/Stepmother's/Guardian's - Work Hours
Mother's/Stepmother's/Guardian's - Primary Language

FATHER'S INFORMATION
Father's/Stepfather's/Guardian's - Marital Status:*

SingleMarriedDivorcedWidowed
Father's/Stepfather's/Guardian's Name:

First NameLast Name
Does Father/Stepfather/Guardian have the same address as Mother/Stepmother/Guardian?

YesNo
Father's/Stepfather's/Guardian's Address:*
Father's/Stepfather's/Guardian's - Cell Phone:
Please enter a valid phone number.
Father's/Stepfather's/Guardian's - Home Phone:
Please enter a valid phone number.
Father's/Stepfather's/Guardian's - Personal Email Address:
example@example.com
Father's/Stepfather's/Guardian's - Employer Name:
Father's/Stepfather's/Guardian's - Work Phone:
Please enter a valid phone number.
Father's/Stepfather's/Guardian's - Work Email:
example@example.com
Father's/Stepfather's/Guardian's - Work Days:
Father's/Stepfather's/Guardian's - Work Hours
Father's/Stepfather's/Guardian's - Primary Language:
Please explain:*
Address and phone to be used for child:

Mother's address and phoneFather's address and phone
I CERTIFY THAT THE ABOVE INFORMATION IS TRUE AND CORRECT.
Signature of Parent/Guardian:*

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Name of Signer:*

First NameLast Name
Date Signed:*

MonthDayYear
Date

CONSENT FOR EMERGENCY MEDICAL TREATMENT - CHILD CARE CENTERS OR FAMILY CHILD CARE HOMES

State of California - Department of Health & Human Services Agency/California Department of Social Services - Form LIC 627 (9/08) (CONFIDENTIAL)
Child's Name:*

First NameLast Name
As the parent or authorized representative, I hereby give consent to WeVillage Ventura, LLC to obtain all emergency medical or dental care prescribed by a duly licensed physician (M.D.), osteopath (D.O.) or dentist (D.D.S.).

This care may be given under whatever conditions are necessary to preserve the life, limb or well being of the child named above.
Child has the following medication allergies:*
Parent or Authorized Representative Signature:*

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Name of Parent or Authorized Representative:*

First NameLast Name
Date Signed:*

MonthDayYear
Date
Home Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone:
Please enter a valid phone number.
Cell Phone: *
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
End of LIC 627

PARENT CONSENT FOR ADMINISTRATION OF MEDICATIONS [BY WEVILLAGE] AND MEDICATION CHART

State of California -[ Health and Human Services/California Department of Social Services, LIC 9221 (8/08)
WeVillage Ventura, LLC

Community Care Licensing Division #285193
Do you need WeVillage, and its employees, to administer any prescription or nonprescription medications to your child at this time?*

YesNo
PARENT'S INSTRUCTIONS:

1. All prescription and nonprescription medications shall be maintained with the child's name and shall be dated.

2. Prescription and nonprescription medications must be stored in the original bottle with unaltered label. Medications requiring refrigeration must be properly stored.

3. Prescription and nonprescription medication shall be administered in accordance with label directions.

4. Written consent must be provided from the parent permitting child care facility personnel to administer medications to he child. Instructions shall not conflict with the prescription label or product label direcitons.
Child's Name:*

First NameLast Name
Child's Date of Birth:*

MonthDayYear
Date
Medication Information :*
I authorize child care personnel to assist in the administration of medications desribed above to the child named above for the following medical condition/s:
Medical Conditions:*
From (Beginning Date): Date* To (Ending Date): Date* daily while in attendance
Signature of Parent/Guardian:*

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Name of Signer:*

First NameLast Name
Date Signed:*

MonthDayYear
Date
MEDICATION CHART

Staff Documentation of Medicine Administration
End of LIC 9221

PLEASE NOTE THE FOLLOWING REGARDING ADMINISTRATION OF MEDICATION:

This form applies to the administration of prescription AND non-prescription medications.

Non-prescription medications include, but are not limited to, diaper cream, sunscreen and other topical non-prescription creams or ointments.

WeVillage is required to have one Medication Administration form for each prescription and non-prescription medication. We know that this is inconvenient, but our staff members are required to keep daily logs of the administration of any prescription or non-prescirption medication on each form.

Additional forms can be obtained by contacting WeVillage or stopping by the front desk while at the Center.

All medications must be in sealed containers with the pharmacy label on them that clearly contains the child's name, the name of the medication, dosages and times of day to be administered, and the expiration date. WeVillage staff members cannot administer medications without the pharmacy label or product instructions. WeVillage also cannot administer exired medications.  No exceptions.

All medications must be handed directly to a staff member each day at the time of drop off.  WeVillage staff members cannot be responsible for administering medications put inside diaper bags or any other like enclosed containers.

Thank you.
Signature of Parent/Guardian:

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Name of Signer:

First NameLast Name
Date Signed

MonthDayYear
Date

IMMUNIZATION RECORDS
Please upload your child's most recent immunization records here:*

Cancelof

MARKETING/ADVERTISING
From time-to-time, WeVillage, and its employees or professional vendors, take photos and/or videos of the daily activities at the Center for promotional purposes. WeVillage uses these photos and/or videos at its Open Houses, on its website and on the social media platforms used by WeVillage.

Accordingly, your child may by included in these photos and/or videos.

We understand that not all parents wish to have their child included in these promotional materials.
Please indicate your election below:*

I consent to my child's inclusion in photos and/or videos for purposes of promotion of WeVillage.I decline to have my child included in photos and/or videos for purposes of promotion of WeVillage.
Signature of Parent/Guardian:*

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Name of Signer:*

First NameLast Name
Date of Signature:*

MonthDayYear
Date

DAILY REPORTING
Using Procare, our WeVillage/Parent communications program, WeVillage can provide progress updates throughout the day of all of the activities that your child participates in. These include, but are not limited, to the following:

- Curriculum updates

- Activities updates

- Diaper changing updates

- Feeding updates

- Special event updates

- Photo updates *

*If you have declined to have photos and/or videos taken of your child for purposes of promotion of WeVillage, any photos and/or videos taken of your child for the purpose of daily updates will not be used for any promotional purposes.

Please let us know who you would to receive daily updates of your child's progress, including yourself, your spouse and any other person you designate.
Would you like to add Mother/Stepmother/Guardian as a Daily Report recipient?*

YesNo
Mother's/Stepmother's/Guardian's Name

First NameLast Name
Cell Phone Number:
Please enter a valid phone number.
Personal Email Address:
example@example.com
Would you to add Father/Stepfather/Guardian as a Daily Report recipient?*

YesNo
Father's/Stepfather's/Guardian's Name:

First NameLast Name
Cell Phone Number:
Please enter a valid phone number.
Personal Email Address:
example@example.com
Would you like to add a third Daily Report recipient?*

YesNo
Additional Daily Report Recipient:*
Signatureof Parent/Guardian:*

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Name of Signer:*

First NameLast Name
Date Signed:*

MonthDayYear
Date

PERSONAL RIGHTS

State of California - Health and Human Services Agency/California Department of Social Services - Form LIC 613A (8/08)
Personal Rights, See Section 101223 for waiver conditions applicable to Child Care Centers.

(a) Child Care Centers. Each child receiving services from a Child Care Center shall have rights which include, but are not limited to, the following:

(1) To be accorded dignity in his/her personal relationships with staff and other persons.

(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.

(3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with daily living functions, including eating, sleeping, or toileting; or withholding shelter, clothing, medications or aids to physical functioning.

(4) To be informed, and to have his/her authorized representative, if any, informed by the licensee of the provisions of law regarding complaints including, but not limited to, the address and telephone number of the complaint receiving unit of the licensing agency and of information regarding confidentiality.

(5) To be free to attend religious services or activities of his/her choice and to have visis from the spiritual advisor of his/her choice. Attendance at religious services, either in or outside the facility, shall be on a completely voluntary basis. In Child Care Centers, decisions concerning attendance at religious services or visits from spiritual advisors shall be made by the parent(s), or guardian(s), of the child.

(6) Not to be locked in any room, building, or facility premises by day or night.

(7) Not to be placed in any restraining device, except as supportive restraint approved in advance by the licensing agency.

THE REPRESENTATIVE/PARENT/GUARDIAN HAS THE RIGHT TO BE INFORMED OF THE APPROPRIATE LICENCING AGENCY TO CONTACT REGARDING COMPLAINTS, WHICH IS:

Community Care Licensing Division, 300 Continental Blvd., #290, El Segundo, CA 90245, (424) 301-3077
TO PARENT/GUARDIAN/CHILD OR AUTHORIZED REPRESENTATIVE:

Upon satisfactory and full disclosure of the personal rights as explained, complete the following acknowledgement.

ACKNOWLEDGEMENT: I/we have been personally advised of, and have received a copy of the personal rights contained in the California Code of Regulations, Title 22, at the time of admission to WeVillage Ventura, LLC, 13335 Ventura Blvd., Sherman Oaks, CA 91423.
Name of Child*

First NameLast Name
Signature of Representative/Parent/Guardian:*

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Name of Signer:*

First NameLast Name
Title of Representative/Parent/Guardian:
Date Signed:*

MonthDayYear
Date
End of LIC 613A - COPY TO BE ELECTRONICALLY FILED WITH CHILD'S RECORDS

PRICING
In addition to the montly tuition and contracted meals fees, WeVillage has the following pricing at the time of this enrollment:

$275.00 one-time registration fee for Cotracts

$275.00 one-time registinos fee for FlexCare

$250.00 refundable deposit (pursuant to the Contract terms set forth below)

$125.00 annual materials fee

$3.00 per minute for early drop off and late pickup before and after the

designated times.

$10.00 potty training

$10.00 single lunch fee

$04.00 snack fee

$35.00 late payment fee

$35.00 returned payment fee

$55.00 wait list fee (booked online)

3% processing fee for all credit card charges

There may be an additional cost for certain special events, field trips or other outings. WeVillage will notify you 2 weeks in advance if such an outing is being offered. Please note that the additional cost must be received by WeVillage no later than five days prior to the event or your child will be removed from the attendance roster.

WeVillage would love to host your child's birthday party! Please contact the Director to get pricing and make reservations.

I understand and acknowledge WeVillage's pricing as outllined above.
Signature of Parent/Guardian:*

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Name of Signer:*

First NameLast Name
Date of Signature*

MonthDayYear
Date

Which program type have you selected:*

FlexcareContract
TERMS AND CONDITIONS - CONTRACT CLIENTS

CONTRACT TERMS AND RELATED FEES
Contract Terms

- I am enrolling my child in the WeVillage child care program selected above for a six month term.

- I understand that I am obligated under the terms of this contract, and any subsequent contracts that I may enter into with WeVillage, to make all monthly tuition payments during the term of this or future contracts regardless of whether or not my child attends on the dates for which I have contracted.

- I understand that at the end of this contract, absent my sixty days' written notice to WeVillage otherwise, this contract will automatically roll over into a new six month contract that is subject to the same terms and conditions as set forth here, excluding tuition rate adjustments made by WeVillage during the contract term.

- I understand that I am required to give WeVillage sixty days' notice from the expiration date of the lease term if I do not wish to have my contract roll over for a new six month term.

- I understand that if I notify WeVillage at least sixty days prior to the contract expiration date that I do not wish to renew this contract, my Refundable Deposit will be refunded to me by WeVillage in a timely manner.

- I understand that in the event WeVillage adjusts its rates during the term of this or subsquent contracts, the new rates will go into effect with the immediately following contract renewal. For example, if WeVillage adjust its rates effective March 1st and this contract rolls over on July 1st, WeVillage will not adjust your rate until July 1st.

- I understand that WeVillage reserves the right to terminate this contract immediately should WeVillage determine that the program is not suitable to the needs of my child. In the event that WeVillage makes such a determination, WeVillage will refund a prorated portion of that month's tuition as well as my Refundable Deposit in a timely manner.

- I understand that, in the event that WeVillage terminates this contract for cause, my refundable deposit and any paid tuitition will be forfeited.

- I understand that if I break the terms of this contract, I am still obligated to make the monthly tuition payments for the duration of the contract term and I will forfeit my Refundable Deposit.

- In the event that my child has a birthday that advances them into another age group (i.e. infant to toddler or toddler to pre-k), my monthly tuition will be changed to the appicable pricing of the new age group effective on the 1st day of the of the month immediately following the month of my child's birthdate. For example, if my current Infant contract expires on November 1st and my child's birthday is on August 15th, on which date my child goes from an infant to a toddler, the currently prevailing toddler rate for the same contract type will go into effect on Septembert 1st and will continue through to the expiration of the contract term. On November 1st, the contract will roll over into a Toddler contract.

- I understand that any changes to this contract must be made, in writing, with the Director of WeVillage.

- I understand that if I add addional care time, it will be subject to the then prevailing rates which may be higher than the rates in this contract.

Fees

- I understand that I will pay a one-time, non-refundable registration fee of $275.00.

- I undestand that I will make a one-time refundable deposit of $250.00, refundable at the time my child ceases coming to WeVillage, provided that the terms of this contract have been satisfactorily met.

- I understand that I will pay an annual materials fee of $100.00 on the date of this contract.

- I am responsible for assuring that the monthly child care tuition and monthly meal plan fee, if applicable, is paid on or before the first day of each month.

- If my payment is not received by the fifth day of each month, I understand that a late payment fee of $35.00 will be assessed and my child will be pulled from the attendance schedule until payment is received in full.

- If my payment is returned for any reason, I understand that a returned payment fee of $35.00 will be assessed and my child will be pulled from the attendance schedule until payment is received in full.

- If my child is dropped off before, or picked up after, the designated start and end times, I understand that a fee of $3.00 per minute will be assessed for the additional care time.

- I understand that in the event of any assessment described above, WeVillage will automatically make an ACH withdrawal or charge my credit card on the same day as the assessement is incurred.

- I understand that in the event that a meal or snack(s) is/are provided to my child, WeVillage will automatically make an ACH withdrawal or charge my credit card on the same day as the cost is incurred.

- I understand that no credit will be extended by WeVillage for vacations, holidays or in the event that the Center is shut down by government mandate due to COVID or any other contagious illness. Holidays include, but are not limited to:

Memorial Day

July 4th and the day before or after July 4, depending on day that

July 4th falls on

Labor Day

Thanksgiving Day and the day after Thanksgiving

Christmas Eve and Christmas Day

New Year's Eve and New Year's Day.

- I understand that WeVillage will also be closed on the following dates in 2024:

February 5, 2024 - Staff Development and Training Day

April 22, 2024 - Passover

May 13, 2024 - Staff Development and Training Day

August 17, 2024 - End of Summer Party

August 19, 2024 - First day of pre-school
I HAVE READ, UNDERSTOOD AND AGREE TO THESE TERMS AND CONDITIONS.
Signature of Parent/Guardian:*

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Name of Signer:*

First NameLast Name
Date Signed:*

MonthDayYear
Date

TERMS AND CONDITIONS - FLEXCARE CLIENTS

Fees
- I am enrolling my child in the WeVillage child care program selected above.

- I understand that I will pay a one-time, non-refundable registration fee of $250.00.

- I agree that I am responsible for paying the fees and costs on the date of each visit and that WeVillage will make an ACH withdrawal from my account or make a charge to my credit card, whichever I have on file with WeVillage.

- If my payment is returned for any reason, I understand that a returned payment fee of $35.00 will be assessed and my child will be barred from further attendance at WeVillage until payment is received in full.

- If my child is dropped off before or picked up after the designated start and end times, I understand that a fee of $3.00 per minute will be assessed for the additional care time.

- I understand that in the event of any assessment described above, WeVillage will automatically make an ACH withdrawal or charge my credit card on the same day as the assessement is incurred.

- I understand that in the event that a meal or snack(s) is/are provided to my child, WeVillage will automatically make an ACH withdrawal or charge my credit card on the same day as the cost is incurred.

- I understand that no credit will be extended by WeVillage for vacations, holidays or in the event that the Center is shut down by government mandate due to COVID or any other contagious illness. Holidays include, but are not limited to, Labor Day, Memorial Day, Thanksgiving Day, the day after Thanksgiving, Christmas Eve, Christmas Day, New Year's Eve and New Year's Day.
Signature*

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Name of Signer*

First NameLast Name
Date Signed:*

MonthDayYear
Date
TERMS AND CONDITIONS

EARLY CONTRACT TERMINATION AND CONTRACT CHANGES
I HAVE READ, UNDERSTOOD AND AGREE TO THESE TERMS AND CONDITIONS.
Signature of Parent/Guardian:*

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Name of Signer:*

First NameLast Name
Date Signed:*

MonthDayYear
Date

TERMS AND CONDITIONS

ACTIVITIES, EXCURSIONS AND EVENTS
- I grant WeVillage, and its employees, permisson for my child to participate in all activies on WeVillage premises.

- i grant WeVillage, and its employees, permission for my child to leave the WeVillage premises, under proper adult supervision, to take neighborhood walks and/or field trips or other excursions by bus or streetcar. WeVillage will provide 10 days' advance notice of any field trip, excursion or other special event.

- I grant WeVillage, and its employees, permission for my child to participate in water play at local parks. I will provide sunscreen and swimming gear and anything else I wish to accompany my child on such excusions.

- I am responsible for completing a non-prescription authorization form, available at the Center's front desk, for administration of sunscreen or any other non-prescription item.

- I understand that extra fees may be charged for certain field trips or excursions. WeVillage will provide 10 days' advance notice of any such event that involves additional costs.

- I understand that any additional costs will be due, in full, five days prior to the event or my child will be pulled from the event roster.
I HAVE READ, UNDERSTOOD AND AGREE TO THESE TERMS AND CONDITIONS.
Signature of Parent/Guardian:*

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Name of Signer:*

First NameLast Name
Date Signed:*

MonthDayYear
Date

TERMS AND CONDITIONS

ILLNESS AND MEDICATION
- I agree that any medications brought to WeVillage for WeVillage, and its employees, to administer to my child will be in sealed containers with the pharmacy label on them and clearly containing my child's name, the name of the medication, dosages and times to be administered and the expiration date. I further understand that WeVillage staff members will not administer expired medication to my child, without exception.

- I agree to hand all medications directly to a staff member each day at the time of drop off. I further agree that WeVillage staff members are not responsible for administering medications put inside diaper bags or any other like enclosed containers.

- In the event that my child is ill, I agree to notify Wevillage of my child's absence.

- I understand that if my child develops a fever over 100 degrees while at the Center, my child will be sent home.

- I agree that I will be readily available at all times to receive a call that my child is ill or in the event of any other emergency that may arise.

- I understand that I must provide WeVillage with a doctor's note releasing my child to return to daycare before my child returns to WeVillage.

- I undestand that in the event my child is sent home with a fever above 100 degrees, my child may not return to WeVillage until 24 fever-free hours have passed and a negative COVID test can be presented.
I HAVE READ, UNDERSTOOD AND AGREE TO THESE TERMS AND CONDITIONS.
Signature of Parent/Guardian:*

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Name of Signer:*

First NameLast Name
Date Signed:*

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Date

GENERAL TERMS AND CONDITIONS
- WeVillage enrollment is open to any child regardless of race, color or religious affiliation provided that WeVillage can meet the needs of the child.

- WeVillage may not be suitable for children with auditory or sensory senstivities. If my child presents with any such symptons, I am responsible for having my child evaluated by a professional and for having a care plan put into place for continued care.

- I understand that WeVillage, and its employees, are required by law to report any sign of child abuse, or suspected child abuse, to the police and the Department of Human Services.

- I undestsand that, due to unforseen circumstances, it may be necessary for WeVillage to adjust my child's schedule. WeVillage will take every step to avoid such schedule changes.

- I agree to provide WeVillage with updated contact and emergency contact information and any other relevant new information in a timely manner.

- I understand that WeVillage is a NO NUT facility, including all tree nuts. Sun butter sandwiches need to be labeld with "sun butter" and brought to the attendtion of a staff member. No peanut butter is allowed.

- I agree to label ALL personal items brought to WeVillage for my child. Such items include, but are not limited to, bottles, bottle ice bag, food storage containters, diaper bag on the outside, blankets, sleep sack, swim gear and all clothing items.

- PLEASE NOTE that WeVillage will not release your child to anyone under the age of 18 years, including siblings. Further, WeVillage will not release your child to any person, including yourself or your spouse, if applicable, visibly under the influence of alchohol or any other substance.

- Authorized persons will be asked to present government-issued photo identification at the time of pickup for verification purposes.
I HAVE READ. UNDERSTOOD AND AGREE TO THESE TERMS AND CONDITIONS, AND TO ALL OF THE TERMS AND CONDITONS STATED THROUGHOUT THIS ENROLLMENT FORM.
Signature of Parent/Guardian:*

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Name of Signer:*

First NameLast Name
Date of Signature:*

MonthDayYear
Date

LIABILITY WAIVER
By signing below, I hereby release and agree to indemnify, defend, and hold harmless WeVillage Ventura, LLC, its representatives, agents, and directors from all claims of laibility for damages and/or injuries incurred by my child in connection with child care provided at WeVillage. I further acknowledge that I have reviewed and evaluated the risks and have determined to use the child care by WeVillage with full knowledge and acceptance of the risks.
Signature of Parent/Guardian:*

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Name of Signer:*

First NameLast Name
Date Signed*

MonthDayYear
Date

PAYMENT AUTHORIZATION
WeVillage accepts payment by ACH or Debit Card/ Visa or Mastercard. ( No AMEX )PLEASE NOTE that there is a 3% processing fee for credit card charges
Which payment option would you like to use?*

ACHCredit Card
ACH Information:*
Visa Mastercard Debit - NO AMEX Credit Card Information (3% Processing Fee on All Credit Card Charges):*
I hereby authorize WeVillage to charge my monthly tuition, daily Flexcare fees, and /or any other costs incurred pursuant to my payment instructions above.

I agree that I will notify WeVillage, in writing, immediately if my payment method changes in any way and I will provide new paymet information.

In the event that my payment is rejected by my bank or credit card company, or if my payment has not been received by the 5th of the month, I understand that my child will be removed from the schedule until WeVillage receives payment in full.
Signature of Account Holder or Credit Card Holder:*

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First NameLast Name
Date of Signature:*

MonthDayYear
Date

FOR WEVILLAGE USE ONLY
Child's Name:
Name of Person Completing Enrollment Form:
Relationship to Child of Person Completing Enrollment Form:
Email Address of Person Completing Enrollment Form:
example@example.com
Home/Cell Phone of Person Completing Enrollment Form:
Please enter a valid phone number.
Child's Birthdate:

MonthDayYear
Date
Child's Gender:
Emergency Contact #1:
ACH Billing Information:
Credit Card Billing Information:
Child Should NOT be included in photos/videos (Notes):
Child's Allergies to Medicines (Alerts):
Child's Other Allergies (Alerts):

Should be Empty:

Welcome to the WeVillage Sherman Oaks Child Registration Process

BEFORE WE BEGIN . . .

CONSENT TO PROCEED ELECTRONICALLY

WEVILLAGE CHILD CARE PROGRAMS

CHILD'S INFORMATOIN

MOTHER'S INFORMATOIN

FATHER'S INFORMATION

CHILD'S PREADMISSION HEALH HISTORY - PARENT'S REPORT

Developmental History (For infants and preschool-age children only) [0-5 years old]

Past Illnesses - Check Illnesses that child has had and specify approximate dates of illnesses:

Daily Routines (For infants and preschool-age children only) [0-5 years old]

CONSENT FOR EMERGENCY MEDICAL TREATMENT - CHILD CARE CENTERS OR FAMILY CHILD CARE HOMES

PARENT CONSENT FOR ADMINISTRATION OF MEDICATIONS [BY WEVILLAGE] AND MEDICATION CHART

MEDICATION CHART

IMMUNIZATION RECORDS

IDENTIFICATION AND EMERGENCY INFORMATION - CHILD CARE CENTERS/FAMILY CHILD CARE HOMES

Additional Persons Who May Be Called In An Emergency

Physician or Dentist to Be Called In An Emergency

Names of Persons Authorized to Take Child From the Facility

MARKETING/ADVERTISING

DAILY REPORTING

PERSONAL RIGHTS

PRICING

TERMS AND CONDITIONS - CONTRACT CLIENTS

TERMS AND CONDITIONS - FLEXCARE CLIENTS

TERMS AND CONDITIONS

TERMS AND CONDITIONS

TERMS AND CONDITIONS

GENERAL TERMS AND CONDITIONS

LIABILITY WAIVER

PAYMENT AUTHORIZATION

FOR WEVILLAGE USE ONLY