Child Enrollment Form

Parent/Legal Guardian Information
Mother's Name/Legal Guardian:*

First NameLast Name
Home Address (If different than child):

StreetCity, State, Zip
Phone Number:*
Please enter a valid phone number.
Email:*
example@example.com
Driver License:*

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Father's Name/Legal Guardian:

First NameLast Name
Home Address (If different than child):

StreetCity, State, Zip
Phone Number:
Please enter a valid phone number.
Email:
example@example.com
Driver License:

Cancelof
Signature:*

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Physician & Emergency Care Facility Information
Pediatrician's Full Name:*

First NameLast Name
Pediatrician's Address:*

StreetCity, State, Zip
Pediatrician's Phone Number:*
Please enter a valid phone number.
In the event a parent cannot be reached to make arrangements for emergency medical care, I authorize Belle's & Beau's to take my child to:
Preferred Emergency Care Facility:*
Covenant or UMC
Emergency Care Facility Address:*

StreetCity, State, Zip
Emergency Care Facility Phone Number:*
Please enter a valid phone number.
I give consent for the center to secure any and all necessary emergency medical care for my child. I give consent for the center to transport my child to the above emergency care facility if needed.
Signature*

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Emergency Contact Information

Please list 1-2 people - other than a parent - that you approve to be contacted in the event Belle's & Beau's cannot get into contact with a parent.
Emergency Contact Name:*

First NameLast Name
Relationship:*
Address:*

StreetCity, State, Zip
Phone Number:*
Please enter a valid phone number.
Emergency Contact Name:

First NameLast Name
Relationship:
Address:

StreetCity, State, Zip
Phone Number:
Please enter a valid phone number.
Signature*

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Authorized Pick Up & Drop Off

I authorize Belle's & Beau's Childcare Center to release my child from the center ONLY with the following people. Please list the name AND phone number for each person. Failure to list name and number can result in an unauthorized person. Children will only be released to a parent, guardian, or to a person designated by the parent/guardian after verification of ID.
Pick Up #1

Full Name & RelationshipPhone Number
Pick Up #2

Full Name & RelationshipPhone Number
Pick Up #3

Full Name & RelationshipPhone Number
Pick Up #4

Full Name & RelationshipPhone Number
Pick Up #5

Full Name & RelationshipPhone Number
Pick Up #6

Full Name & RelationshipPhone Number
Signature*

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Rate & Terms Agreement
I have received and read the Belle's & Beau's Childcare Center Parent Handbook and I agree to comply with all the provisions in this agreement. Belle's & Beau's Childcare Center will provide care for my child under the following conditions:
- Parent/Legal Guardian compliance with all policies and regulations stated in the Parent Handbook.
- All fees will be paid on time. Except for late charges, all fees are due on Wednesday morning (or first day of your child's attendance for the week and are payable in cash, check, or credit card. Late fees are due at the time of arrival to pick up your child.
- Refunds are not given for days the child is absent (sick, vacation, etc.) or when the center is closed (holidays or staff development). Sick care is not available. It is the parent's responsibility to make substitute arrangements.
- A two-week notice is required when withdrawing a child from the program. Parents are responsible for the contracted rate for those two weeks, whether services are used or not.
- Parents arriving after center closing time of 6:30pm must pay the late fee of $10 per quarter hour. Parents must notify the provider if they are delayed beyond their scheduled arrival time.
- A registration fee of $100 is due at the time of enrollment.
- This rate is valid for the length of your family's enrollment at Belle's & Beau's Childcare Center. Policies may be changed at any time and at the sole discretion of the owner. Any changes will be made in writing and given to the parent/legal guardian in th eform of an updated Parent Handbook with at least a two-week notice.
Signature*

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Should be Empty:

General Information

Parent/Legal Guardian Information

Physician & Emergency Care Facility Information

Emergency Contact Information

Authorized Pick Up & Drop Off

Receipt of Written Operational Policies:

Rate & Terms Agreement