Enrollment form

CHILD INTAKE PACKET

EMERGENCY CONTACTS AND RELEASE PERSONS
Please initial the statements below regarding Emergency Contacts and Alternative Release Persons.

I understand that I must notify Childcare Discovery Center if someone other than the listed parent/guardian will be picking up my child for any reason. All persons listed as an Emergency Contact will be asked to present an approved form of identification at the time of pick up. All persons listed below must be at least 18 years or older unless he/she is the parent of the child.I understand that the Parents shall be afforded unlimited access to their children and to the providers caring for their children during the normal operation or whenever their children are in the care of the providers, unless parental contact is prohibited by court order. State Law 109.8(2).I understand that if I have not provided a copy of the No Contact Order, Childcare Discovery Center is required to allow access to both parents.
Emergency Contacts and Alternative Release Persons
Contact #1 Name:
Relationship to Child
Cell Phone
Home Phone
Home Address

Home Address

Street Address Line 2

CityState / Province

Zip Code
Employer
Employer’s Address
Work Phone/Extension
Work Hours:
Contact #2 Name:
Relationship to Child
Cell Phone
Home Phone
Home Address

Home Address

Street Address Line 2

CityState / Province

Zip Code
Employer
Employer’s Address
Work Phone/Extension
Work Hours:
Contact #3 Name
Relationship to Child
Cell Phone
Home Phone
Home Address

Home Address

Street Address Line 2

CityState / Province

Zip Code
Employer
Employer’s Address
Work Phone/Extension
Work Hours:
Parent/Guardian Signature

Clear
Date

MonthDayYear
Date

EMERGENCY MEDICAL CONSENT
Childs Name
Birth Date

MonthDayYear
Date
Present medication:
Allergies/Conditions:
Permission for medical care in parental absence. (This form must be presented upon admission for treatment)
CHILD’S FULL NAME
In the event that my child may require emergency medical and /or surgical care while I am out of the City or unable to be reached, I hearby give my consent to medical and/or surgical treatment to the nearest hospital and Doctor provide this care. If my child needs Dental care our family dentist is
include address and phone)or his or her designee toprovide this care. If my child needs Dental care our family dentist is Doctor provide this care. If my child needs Dental care our family dentist is
include address and phone)or his or her designee to (include

address and phone If a dentist is not chosen, the dentist on call will be chosen. I agree to pay all the costs and fees contingent on any emergency medical care and/or treatment for my child as secured or authorized under this consent.
Parent/Guardian #1:
Relationship to Child
Cell Phone
Home Phone
Home Address

Home Address

Street Address Line 2

CityState / Province

Zip Code
Social Security Number
State
Parent/Guardian #2:
Relationship to Child
Cell Phone
Home Phone
Home Address

Home Address

Street Address Line 2

CityState / Province

Zip Code
Social Security Number
State
Hospital Preference
Religious Preference
Insurance Carrier
Policy Number
EVERY EFFORT WILL BE MADE TO NOTIFY PARENTS IMMEDIATELY IN CASE OF AN EMERGENCY
This consent will be in effect beginning blanks and continuing while the child is enrolled in this childcare facility.
Father's Signature

Clear
Mother's Signature

Clear

TRANSPORTATION AUTHORIZATION

(for children 4 years of age or older)
Childcare Discovery Center has permission to drop off and pick up my child, on a daily basis from Elementary School.
I understand that I must notify Childcare Discovery Center by 2:30 p.m. if my child does not need to be picked up from the school for any reason and by 12:30 on early releases.
My child if free of any communicable diseases. I agree to alert the center if this changes.
My child Type a label , has a physical on file to their school Type a labeland I give permission for ChildCare Discovery Center to access this.
ChildCare Discovery Center access to this.

In case of emergency, I authorize The Childcare Discovery Center to call 911 and have emergency personnel transport my child to the nearest medical facility and consent to any necessary treatment and/or hospital care to be rendered under the general supervision of a physician or surgeon licensed to practice medicine in the state of Iowa.

In case of emergency, please contact:
Name
Relationship
Phone
Name
Relationship
Phone
I understand that all children under 7 will sit in a booster seat in the back of the vans. Once they no longer need a booster, they may sit in the front.
Signature

Clear
Date

MonthDayYear
Date

ENROLLMENT AGREEMENT
Name of Child
Name of Parent/Guardian
Please initial each section below, and sign and date the last page.
Tuition and Fees
Initial Registration Fee: I understand that a registration fee will be due by the first day of enrollment. The registration fee will secure my child's enrollment at Childcare Discovery Center. The fee is $25.00 per family and includes a $5.00 deposit for a key.
Initial Tuition: $ per week is the current tuition rate for my child and is due on Monday for the week. I understand that rates are subject to change with reasonable notice, as conditions require. Tuition payments received after Monday will be subject to a $10.00 late fee. I understand that timely tuition payments are required to maintain my child's enrollment status at Childcare Discovery Center. I understand that enrollment will be terminated if my account becomes one week past due. I understand that there are no exceptions to this policy.
Initial Schoolage Fees: I understand that there will be $10.00 fee applied for each full day my schoolage childcare attends, or any no school day that I do not notify Chilcare Discovery Center of his/her absence. Additionally, I understand that there is an additional summer fee for the schoolage program, to be determined in each year before the Summer Session begins.
Initial Late Pick Up: I understand that my school is open from 5:30 am until 6:00 pm Monday through Friday, except for holidays. I understand. that if I fail to pick up my child by the scheduled closing time, I will be charged a fee of $1.00 per child for every minute, beginning at 6:01 pm.
Initial Returned Checks: I understand that a $35.00 processing fee will be added to all returned checks. I understand that if a check is returned for any reason, I will be required to pay by an alternative method of payment for the next 6 month period.
Initial Terminated Enrollment: I understand that if my child is disenrolled for any reason, and my account has an outstanding balance, I am responsible for paying this balance within one week. I understand that terminated accounts with an outstanding balance will be subject to additional collection efforts, including but not limited to, small claims suit through Webster County Courthouse, and additional court, attorney and/or garnishment fees will be added to the original past due balance.
Initial Vacation: I understand that after three (3) months of consistent enrollment, timely payments and am enrolled full time, I am eligible for fifteen (15) vacation days during which tuition is waived for non-attendance. I understand if I am not full time, I must pay tuition regardless of absent days, closings, or holidays.
Daily Procedure
Initial Daily Attendance and Attendance Guidelines: I understand that my child may attend for up to ten (10) hours per day. I understand that my child will not be able to attend the center if it is one hour after their scheduled time unless notification has been received.
Initial Daily Sign In and Sign Out: I agree to sign my child in and out every day using the school's attendance procedure. I understand that I am required to enter the school to drop off and pick up my child and that I must escort my child to and from their designated classroom.
Initial Picture/Photo Release: I understand that Childcare Discovery Center may take videos or pictures of my child throughout the day. I do/do not (circle one) give permission for these images to be used for external viewing, including
Initial Illness: I understand that if my child becomes ill during the day, I will be notified to pick up my child within a reasonable amount of time. If my child is exposed to or contracts a contagious disease, I agree to notify the school as soon as possible.
Initial Withdrawal: I understand that I must provide a two (2) week written notice to withdraw my child from Childcare Discovery Center. I understand that I am responsible for tuition payments for these two (2) weeks, whether or not my child attends.
Absences and Closings
Initial Absences: I agree to notify the school one hour before my child's scheduled time if my child will be absent or late on any day. I understand that I may not bring my child to the school if I am one hour late without calling the school to notify them.
Initial Holidays: I understand that Childcare Discovery Center will be closed on the following holidays: New Year’s Day, Memorial Day, Independence Day, Labor Day, Thanksgiving Day, day after Thanksgiving, Christmas Eve and Christmas Day. I understand that Childcare Discovery Center does not offer tuition credit for these holidays.
Initial Inclement Weather: I understand that it is Childcare Discovery Center’s intention to be open every weekday of the year, except for holidays. I also understand that inclement weather, natural/national disaster, or major building issues
my interrupt service occasionally. I understand that, should the school be closed for an extended period of time, I will continue to be responsible for tuition payments for up to 3 business days.
Policies and Licensing Regulations
Initial State Licensing Requirements: I understand that the child care regulations of the state of Iowa may prevail over this list of policies when the state regulation is stricter. I also understand that my continued enrollment in Childcare Discovery Center is contingent on my agreement to adhere to all policies and state regulations.
Initial Additional Paper: I understand that I am required to provide Childcare Discovery Center a copy of my child’s annual physical examination, as well as the most current immunization record .
Initial Family Handbook: I have been given a copy of the Parent Handbook and agree to abide by its guidelines.
Statement of Health
I certify that my child is free of communicable diseases and in good health.
Signature

Clear
Date

MonthDayYear
Date
Sunscreen/diaper ointment/bug spray/lotions etc.

I give my permission for Childcare Discovery employees to apply these items as needed. I understand that these items will be provided by the child’s parent.
Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

CHILD INTAKE PACKET

CHILDCARE DISCOVERY CENTER ENROLLMENT INFORMATION

Child Information

Parent/Guardian Information

EMERGENCY CONTACTS AND RELEASE PERSONS

Emergency Contacts and Alternative Release Persons

EMERGENCY MEDICAL CONSENT

EVERY EFFORT WILL BE MADE TO NOTIFY PARENTS IMMEDIATELY IN CASE OF AN EMERGENCY

TRANSPORTATION AUTHORIZATION

ENROLLMENT AGREEMENT

Tuition and Fees

Daily Procedure

Absences and Closings

Policies and Licensing Regulations

Statement of Health

Sunscreen/diaper ointment/bug spray/lotions etc.

I give my permission for Childcare Discovery employees to apply these items as needed. I understand that these items will be provided by the child’s parent.