Before and After Care Registration Form

Before and After Care Registration

3707 N. Market St, Wilmington, DE 19802
Enrollment Date
Withdrawal Date
Please select the service(s) you are applying for.*
Student Information
Student's Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birth Date*

MonthDayYear
School Name*
Age*
Grade*
Gender*

MaleFemale
Parent/Guardian Information #1
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Alternate Number
E-mail*
example@example.com
Employer/School

NameHours
Employer/School Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer/School Phone Number
Please enter a valid phone number.
Extension
Parent/Guardian Information #2
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Alternate Number
E-mail
example@example.com
Employer/School

NameHours
Employer/School Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer/School Phone Number
Please enter a valid phone number.
Extension

Non-Parent/Guardian Emergency Contact Information
1. Emergency Contact's Name*

First NameLast Name
Emergency Contact's Relationship*
Emergency Contact's Phone Number*
Emergency Contact's Alternate Number
Emergency Contact's Email
example@example.com
Emergency Contact's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact's Employer/School Name
Name
Hours
Emergency Contact's Employer/School Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact's Employer/School Phone Number
Please enter a valid phone number.
Extension
2. Emergency Contact's Name

First NameLast Name
Emergency Contact's Relationship
Emergency Contact's Phone Number
Please enter a valid phone number.
Emergency Contact's Alternate Number
Please enter a valid phone number.
Emergency Contact's Email
Emergency Contact's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact's Employer/School
Name
Hours
Emergency Contact's Employer/School Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact's Employer/School Phone Number
Please enter a valid phone number.
Extension
3. Emergency Contact's Name

First NameLast Name
Emergency Contact's Relationship
Emergency Contact's Phone Number
Please enter a valid phone number.
Emergency Contact's Alternate Number
Please enter a valid phone number.
Emergency Contact's Email
Emergency Contact's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact's Employer/School Name
Name
Hours
Emergency Contact's Employer/School Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact's Employer/School Phone Number
Please enter a valid phone number.
Extension
Hours of attendance will be from Time* to Time* . NOT TO EXCEED 10 HOURS.
Please check the days your child will attend Before and After Care (check all that apply)*

MondayTuesdayWednesdayThursdayFriday

Child Release Information

Persons to whom child may be released to other than parent(s)/guardian(s) and emergency contacts.
1. First and Last Name
Please enter first and last name
2. First and Last Name
Please enter first and last name
3. First and Last Name
Please enter first and last name
4. First and Last Name
Please enter first and last name
5. First and Last Name
Please enter first and last name
6. First and Last Name
Please enter first and last name
7. First and Last Name
Please enter first and last name
8. First and Last Name
Please enter first and last name
***PALW will not release a child to anyone under the age of 16 without prior written parental consent. ***
Is there a court ordered custody or visitation arrangement?*

YesNo
Sibling Information

Please list any siblings who are also enrolled in care.
First and Last Name
Please enter first and last name
Age
First and Last Name
Please enter first and last name
Age
First and Last Name
Please enter first and last name
Age
First and Last Name
Please enter first and last name
Age
First and Last Name
Please enter first and last name
Age

Medical Information Permission to Treat
Healthcare Provider*
Phone Number*
Please enter a valid phone number.
Insurance Provider
Policy Number
Healthcare Provider's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Allergies
Reaction
Special Disabilities
Existing Medical Conditions
Additional Information
Current Illnesses and Medications (Name, Dosage, Frequency)
Previous Illnesses or Injuries
In case of an emergency, may we release this information to medical personnel?*

YesNo
I, Parent's/Guardian's name* herby authorize emergency medical treatment for my child, Child's name* in the event I cannot be contacted to grant permission to treat. I understand that I will be financially responsible for the cost of such treatment.
Signature*
Date*

MonthDayYear
Date

PALW Child Care Center Payment and Fees Policy

Effective March 23, 2024

Weekly fees are due by the close of business on Friday for the upcoming week. Payments falling behind by two weeks or more are grounds for dismissal. All payments should be made on the Procare App. The center does not accept cash or checks for payment.

It is important to be on time to pick up your child. It compromises your child's sense of security when you are late. If you are running late, please call so that we can plan accordingly. There is a $1 per minute/child late fee that will be added to your weekly invoice/bill. Ongoing lateness may result in dismissal from the program. If no contact has been made by you or another authorized person about your lateness, the authorities will be contacted per state regulations.

Each family will be granted one weeks' vacation tuition free. Two weeks' written notice is required for vacation or withdrawal. If written notice is not given, fees will contiune to accrue throughout the vacation period. If written notice is not given for withdrawal, fees will contiune to accrue until proper notice is received.

Subsidies are accepted through Purchase of Care (POC) and other agencies. Written documentation of proof of POC is required before your child/children can start.

If your child is absent from care for sickness, unscheduled vacation, or any other situation, payment is still required. You will be billed weekly unless a vacation has been approved or withdrawal has been processed.

Referral bonuses will be granted to families who have referred individuals once the referred child completes 90 days. The bonus will be in the form of a tuition credit.

* My signature indicates my understanding and agreement to this policy
Signature*
Date*

MonthDayYear
Date

Policy and Procedure Information
I have received and read the Parent Handbook and understand my commitent to the program. I have shared the necessary information with my children. We both understand that failure to adhere to the policies and procedures may result in dismissal from the program. I also acknowledge receipt of the "Parents Right to Know" notice as part of this application.

Parent Handbook

https://palw.org/wp-content/uploads/2024/04/PALW-Early-Learning-Center-Parent-Handbook-POC-2023.pdf
Signature*
Date*

MonthDayYear
Date
PARENT/GUARDIAN RIGHT TO KNOW NOTICE

UNDER THE DELAWARE CODE YOU ARE ENTITLED TO INSPECT THE ACTIVE RECORD AND COMPLAINT FILES OF ANY LICENSED CHILD CARE FACILITY. TO REVIEW A CHILD CARE FACILITY RECORD CONTACT: Administrative Specialist, Office of Child Care Licensing, 3411 SILVERSIDE ROAD, CONCORD PLAZA ǀ HAGLEY BUILDING, WILMINGTON, DELAWARE 19810, phone (302) 892-5800

You may also view substantiated complaints and compliance review histories for the past three years by visiting https://education.delaware.gov/families/occl/child_care_search/

By signing below, I acknowledge I received this notice as part of the application packet.
Signature*
Date*

MonthDayYear
Date
PARENT/GUARDIAN PERMISSION FOR DVD/TV VIEWING

Children over the age of 2 years old may have an educational movie or program incorporated into their curriculum. Movies shown will be age appropriate and not exceed one hour in length.

By signing below, I hereby authorize my child to watch educational programs.
Signature*
Date*

MonthDayYear
Date
PARENT/GUARDIAN PERMISSION TO PHOTOGRAPH AND DISPLAY IMAGES

Your child's photo may be displayed throughout the facility, on the website, PALW marketing material or on the PALW's social media pages.

By signing below, I hereby authorize PALW Child Care to photograph display images of my child.
Signature*
Date*

MonthDayYear
Date
PARENT/GUARDIAN PERMISSION FOR COMPUTER USAGE

Children over the age of 2 years old will have the opportunity to occasionally play educational games on the computer. Children will be closely supervised to ensure that age appropriate and educational websites are being viewed while using the internet. Computer time will not exceed one hour in length.

By signing below, I hereby authorize my child to use the computer.
Signature*
Date*

MonthDayYear
Date
PARENT/GUARDIAN PERMISSION TO SLEEP ON A MAT

Children between 12-18 months will transition from sleeping in a crib to a cot, mat, or bed, when they are able to walk.

I hereby authorize my child to sleep on a cot, mat, or bed.
Signature*
Date*

MonthDayYear
Date
PARENT/GUARDIAN PERMISSION FOR ROUTINE OUTINGS

I hereby give permission for my child to attend and participate in onsite and offsite trips and activities including but not limited to: swimming, skating, bowling, nature walks, neighborhood walks, and various sports and be transported to field trips and other outside adventures by the PALW's authorized transportation vehicles.
Please list any special needs or problems which might require special attention during transportation and directions on how to handle the need or problem.
Signature*
Date*

MonthDayYear
Date
PARENT/GUARDIAN PERMISSION FOR SWIMMING AND WATER ACTIVITIES
This is a fill in the Child's Name* has my permission to participate in any swimming activity/outing with the PALW Before and After Care. I understand my child will be under the supervision of PALW staff members on site and/or a certified lifeguard during any water activity.
Please select the option that best describes your child.*

My child is a swimmerMy child is a non-swimmer
Signature*
Date*

MonthDayYear
Date
Please upload your child's immunization records.

Cancelof
Please upload your child's physical.

Cancelof
Please upload your child's 504 plan if applicable.

Cancelof
Please upload your child's IEP plan if applicable.

Cancelof
Should be Empty:

Before and After Care Registration

Student Information

Parent/Guardian Information #1

Parent/Guardian Information #2

Non-Parent/Guardian Emergency Contact Information

Medical Information Permission to Treat

Policy and Procedure Information