Club iNFiNiTi Early Learning Center: Siloam Springs

Club iNFiNiTi Early Learning Center: Siloam Springs

Enrollment Form
We welcome you to the Club iNFiNiTi Early Learning Center Siloam Springs and to the partnership we will share during your child's early years. The need for good quality early education is great, and Club iNFiNiTi's core focus is strenghtening our community with outstanding education through committed and knowledgeable leaders.

Club iNFiNiTi's Core Values are:
- Helping Children reach their full potential
- Cultivating compassion
- Committed to serving families
- Striving for excellence
As an Arkansas Better Beginnings (ABB) program, Club iNFiNiTi has chosen to meet quality standards that are substantially higher than the minimum requirements. Our goal is to help your child explore and begin to understand the world around us and to lay the foundation for future academic pursuits.

If you have questions, please call us. Please talk to us often. Thank you for choosing Club iNFiNiTi Early Learning Center Siloam Springs. We're glad you are here!

Warmly,

Corey Farrell & Jim Mootz

479-549-3727
Child's Personal Data Sheet
Child's name*

First NameMiddle NameLast Name
Gender*

MaleFemale
Date of Birth*

MonthDayYear
Date
Age*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Which program are you enrolling your child for?*
Please enter your child's start date:*

MonthDayYear
Date
Parent or Legal Guardian Information
Parent/Guardian 1*

First NameLast Name
Relation to Child*
Place of Employment
Work Days
Work Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Which is your preferred emergency contact number?

CellWork
Email*
Parent/Guardian 2

First NameLast Name
Relation to Child
Place of Employment
Work Days
Work Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Which is your preferred emergency contact number?

CellWork
Email
Emergency Contact Information
Emergency Contact Name (if parent or guardian is not available)*

First NameLast Name
Relation to Child
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Number
Please enter a valid phone number.
Emergency Number (Secondary)
Please enter a valid phone number.
Is this person authorized to take the child from the center*

YesNo
Other Authorized Pickups
Name

First NameLast Name
Relation
Phone Number
Please enter a valid phone number.
Name

First NameLast Name
Relation
Phone Number
Please enter a valid phone number.
Name

First NameLast Name
Relation
Phone Number
Please enter a valid phone number.
Will your family be using Vouchers?

yesNo
Medical Information
In accordance with DHS guidelines, I agree to provide a copy of my child's vaccination record within 10 days of enrolling:

Clear
Child's Physician
Emergency Treatment Facility
Facility Phone Number
Please enter a valid phone number.
Facility Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
For the following sections, if you do not have anything to report, please write "none." These sections are required to complete enrollment.
Disease History: Please list any condition or prior disease of which we should be aware (such as a heart condition, diabetes, seizures, history of measles, chicken pox, etc.)*
List any allergies your child has (such as bees, peanuts, dairy). Dietary or life threatening allergies require documentation from a doctor*
List any dietary needs that we should know about. Dietary or life threatening allergies require documentation from a doctor*
List any physical, mental, or other condition(s) that may require special attention: Please contact a director if your child has a developmental disorder or physical disability*
List all medications, both prescribed and over the counter, that your child is currently taking*
Authorizations
I hereby * written permission for the use of suntan/sunscreen for my child. School age children may apply sunscreen themselves with supervision. In accordance with Minimum Licensing Requirements: DCCECE/Child Care Licensing Unit: 1100.1101.17.
Signature of parent/guardian (use mouse or touch screen to sign)

Clear
Date

MonthDayYear
Date
I hereby * my written consent and permission for the taking of photographs and/or video of my child at the Child Care Facility or any event/location where they are participating and waive and/or assign any and all rights (including copyright) in such media to Club Infiniti, LLC. Club Infiniti, LLC, as the sole owners of such media, shall have the exclusive right to control and determine the use, display, performance, reproduction and dissemination of any such photographs and/or videos.
Signature of parent/guardian (use mouse or touch screen to sign)

Clear
Date

MonthDayYear
Date
Tick Release Form: I hereby give permission either over the phone or in person for Club directors or teachers to pull a tick off my child. I have been notified that there is a chance that the head of the tick may not be able to get pulled out. (Depending on tick and tick depth) When I sign this form, I agree to not hold Club iNFiNiTi responsible for anything that may result from pulling the tick(s) out of my child.

Clear
Acknowledgments

This is a statement of verification that I have been informed that childcare licensing/child maltreatment investigators and/or law enforcement may possibly interview my child for the purpose of determining licensing compliance or for investigative purposes. In accordance with MLR: DCCECE/Child Care Licensing Unit: 200.201.4
Signature

Clear
Date

MonthDayYear
Date
This is to acknowledge that I have received a list of Kindergarten Readiness Skills for my Child 3 and 4 years old. In accordance with Minimum Licensing Requirements: DCCECE/ Child Care Licensing Unit 200.201.5 Signature:

Clear
Date

MonthDayYear
Date
I acknowledge that my child will be able to follow the General Behavioral Expectations listed below:

To be kind and respectful to others, oneself, and iNFiNiTi Child Care property.
To be safe while being transported on a bus or van and to not distract the driver with disruptive behavior.
No hitting, biting, punching, throwing, pushing, pinching, hair pulling, or otherwise hurting themselves or others.
No name calling, teasing, or belittling of other children or other families.
No intentionally breaking anything, hitting, or punching walls.
No running, wrestling, or climbing inside unless in designated areas.
Children may not pick up other children.
No leaving the center or playground without a teacher or parent. Children will not be allowed to be left alone outside or inside the center without adult supervision, even when the parent is here.
All food and drink will remain in designated areas of the center and classrooms. For safety reasons, no gum-chewing is allowed by the children.
If a child cannot meet these expectations, a parent conference will be scheduled to address the issue and come up with a behavioral plan. If the behavioral issue is not resolved within a timely manner or if the nature of the behavioral problem is so severe that the child's or other children's safety is at risk, the child will not be allowed to continue attending Club iNFiNiTi. All students are subject to a trial period when first attending Club iNFiNiTi.
This is a statement of verification that I have been informed of the behavior guidance policy practiced. In accordance with Minimum Licensing Requirements: DCCECE/ Child Care Licensing Unit 500.501.7 Signature:

Clear
Date

MonthDayYear
Date
This is a statement of verification that I have received information regarding Shaken Baby Syndrome in accordance with Carter's Law (all parents of infants). In accordance with minimum Licensing Requirements: DCCECE/Child Care Licensing Unit: 600.604.1.n Signature:

Clear
Date

MonthDayYear
Date
Obligation to Serve Infants in the CACFP
I * the type(s) of formula offered by the childcare provider.
If declined, please state the formula you will provide for your infant.
I * the meals/snacks offered by the childcare provider.
Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Club iNFiNiTi Early Learning Center: Siloam Springs

Child's Personal Data Sheet

Parent or Legal Guardian Information

Emergency Contact Information

Other Authorized Pickups

Medical Information

Authorizations

Acknowledgments

Obligation to Serve Infants in the CACFP