Building Blocks Learning Center Enrollment Form 2024

Building Blocks Learning Center

Enrollment Form
To be completed by center:
Enrollment Date:
To be completed by center.
Withdrawal Date:
To be completed by center.
Child's Information
Full Legal Name as show on birth certicate: *

First NameMiddle NameLast Name
Preferred Name
Please upload a copy of your child's birth certificate or hospital record.*

Cancelof
Date of Birth*

MonthDayYear
Date
Gender*
Ehtnicity*
Race*
Hispanic?*
Tribal Affiliation
Child Resides With*
Primary Language Spoken in Home*

Please fill in your child's schedule:*

	MONDAY	TUESDAY	WEDNESDAY	THURSDAY	FRIDAY
Arrival Time
Departure Time

It is your responsibility to clock your child in and out each day that your child attends!

To ensure that we have adequate staff to meet all children’s needs, please adhere to your schedule. Notify us in advance of any changes you may need to make to your schedule.

Household Information
Primary Caregiver's Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Social Security #*
We prefer to receive your full social security #, but the last 4 digits will work as well.
Email*
example@example.com
Phone Number: Home / Mobile*
Please enter a valid phone number.
What type of phone is this?*
Is the primary caregiver currently employed?*

YesNo
Employer Name*
Phone Number: Work*
Please enter a valid phone number.
Employer Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Would you like to provide details for a second caregiver?*

YesNo
Additional Caregiver's Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Social Security #*
We prefer to receive your full social security #, but the last 4 digits will work as well.
Email*
example@example.com
Phone Number: Home / Mobile*
Please enter a valid phone number.
What type of phone is this?*
Is the secondary caregiver currently employed?*

YesNo
Employer Name*
Phone Number: Work*
Please enter a valid phone number.
Employer Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

CACFP

Building Blocks Learning Center participates in the Child and Adult Care Food Program (CACFP) administered by the United States Department of Agriculture. Please help us comply with the requirements of the CACFP by answering the following questions. This information is necessary to decide the level of CACFP reimbursement we are eligible to receive for the meals served to children in our program. This information is treated as confidential information. All participants in our program receive their meal free of charge, but the determination of eligibility category affects the amount of federal funding we receive. Foster Children: A foster child enrolled in our program that is the legal responsibility of a welfare agency, or court may be certified as eligible for free meals regardless of your household income.
Do you or anyone in your household receive SNAP benefits?*
SNAP is the Supplemental Nutrition Assistance Program - formerly the Food Stamp Program.
Please enter your SNAP case number.*
Household Members

Please list all household members below:
Child's Name*

First NameLast Name
Caregiver Name*

First NameLast Name
Caregiver Name 2*

First NameLast Name
Please list the names of any additional people in your household.*
What is the total household income?
Enter Household Income* per *

Local Emergency Contacts:

State Regulations require that you list two people we may call in the event you cannot be reached in an emergency. Please do not list yourself or the person you selected as second caregiver.
CONTACT #1: Name (First and Last)*
CONTACT #1: Relation to Child*
CONTACT #1: Phone Number*
Please enter a valid phone number.
What type of phone is this?*
CONTACT #2: Name (First and Last)
CONTACT #2: Relation to Child
CONTACT #2: Phone Number
Please enter a valid phone number.
What type of phone is this?
Do you wish to authorize anyone other than the emergency contacts listed above to pick up your child?*

YesNo
Name (First and Last)*
Relation to Child*
Phone Number*
Please enter a valid phone number.
What type of phone is this?*
Do you wish to authorize anyone else to pick up your child?*

YesNo
Name (First and Last)*
Relation to Child*
Phone Number*
Please enter a valid phone number.
What type of phone is this?*
Do you wish to authorize anyone else to pick up your child?*

YesNo
Name (First and Last)*
Relation to Child*
Phone Number*
Please enter a valid phone number.
What type of phone is this?*
Pediatrician's Name*
Pediatrician's Phone Number*
Please enter a valid phone number.
Preferred Hospital*
Preferred Hospital's Phone Number*
Please enter a valid phone number.

ASQ - Consent Form
The Ages & Stages Questionnaires® (ASQ®) are used to screen young children ages 1 month to 6 years to help determine if their development is on schedule—or if further evaluation may be needed. ASQ also helps parents, together with providers, learn more about a child's strengths and areas that may need support.

The first 5 years of life are very important for your child because this time sets the stage for success in school and later life. During infancy and early childhood, your child will gain many experiences and learn many skills. It is important to ensure that each child’s development proceeds well during this period.
Please read the text below and mark the desired space to indicate whether you will participate in the screening/monitoring program.*

I have read the information provided about the Ages & Stages Questionnaires ThirdEdition (ASQ-3)and ASQ-SE and I wish to have my child participate in the screening/monitoring program.I would like to administer the ASQ-3 and/or the ASQ-SE at home with my child. I do not wish to participate in the screening/monitoring program. I have read the provided information about the Ages and Stages Questionnaires, Third Edition (ASQ-3)and understand the purpose of this program.
Signature*

Clear
Date*

MonthDayYear
Date
Child's Name*

First NameLast Name
Child's Date of Birth*

MonthDayYear
Date
If child was born 3 or more weeks prematurely, # of weeks premature?
Child's Primary Care Physician*

Consent for Emergency First Aide & Transportation
I hereby give permission that my child, child's name*, may be given emergency treatment by a staff member at Building Blocks Learning Center. I agree not to hold the director, owner, company, board members, or any staff member responsible for any injury sustained by my child while in the care of this facility. Furthermore, in the event of an emergency, I give permission for my child to be transported to the nearest emergency facility by the most expedient means necessary and that neither staff, nor the director of this facility, nor the company, nor its board members will be held responsible for injuries sustained to my child while in transit.
Signature*

Clear
Date*

MonthDayYear
Date

Consent for Medical Care and Treatment
In the event that I cannot be contacted immediately, I give permission that any medical treatment deemed necessary by an attending physician may take place. I again, hold Building Blocks Learning Center and all its employees NOT liable.
Signature*

Clear
Date*

MonthDayYear
Date

Photo Release
TLC Development Centers participates in the New Mexico PreK Program, administered by the New Mexico Early Childhood Education and Care Department (ECECD) and the Public Education Department (PED) along with our Contractor, UNM Continuing Education. These partners ask permission to take photographs and/or to videotape your child during their time in the NM PreK classroom. We are asking your permission to take photographs of or film of your child. Copies may be used by us, ECECD, PED or UNM-CE in ongoing research, reports, marketing materials to promote New Mexico PreK, etc. Pictures/film of your child may be used for training purposes or in future professional publications. For all of the above, we require your permission.

If you do not want your child’s photograph taken at all, you have the option of declining. Thank you for your cooperation and support.

The undersigned parent or legal guardian does hereby consent for their child to be photographed or videotaped, and does hereby authorize Building Blocks Learning Center, the State of New Mexico, or its contractor, UNM- Continuing Education staff to take photographs or videotapes, which will be used for research, training, brochures, reports, marketing, and the like. The undersigned does hereby release Building Blocks Learning Center, the State of New Mexico or its contractor, UNM-CE staff from any and all claims for damages for libel, slander, invasion of the right of privacy, or any claims based on the use of said material. This includes compensation of any sort now or in the future, in the event that your child’s photograph or videotape is used in any of the aforementioned materials including professional publications, marketing, training, reports, etc. developed by NM PreK and their contractor, UNM Continuing Education.
Please check the box that applies.*

I authorize my child to be videotaped and/or photographed and the use of my child’s image forpublication in reports, professional articles and books, professional development, andpromotional/marketing materials.I do not want my child to be videotaped or photographed.
I CERTIFY all of the following: This form has been explained to me and/or I have read the contents of this form, or the contents have been read to me. I understand the contents of this form and/or the explanation of the contents of this form. All blanks or statements requiring insertion or completion were filled in and all items not applicable were stricken before I signed.
Signature*

Clear
Date*

MonthDayYear

Tuition Agreement
I understand that tuition is subject to change with advance notice and:
- Tuition rates are based on a 9 hour day. If your child is here longer than 9 hours on any given day, you will be charged $8 per hour for excess hours.
- ECECD Contract families who exceed their allotted contracted hours will be charged $8 per hour in excess of allotment.
- ECECD Contract families who do not have a copayment at the time of enrollment must still enroll in Tuition Express.
- All monthly payments are due by the 5 of each month.
- Weekly tuitions are due in advance each Monday.
- Payments through Tuition Express are required for all families.
ECECD Contract:*
Monthly Co-Pay:*
Please enter the monthly co-pay amount listed in your ECECD Contract.
Today's Date*

MonthDayYear
Date
Age in Months*
Daily Rate:*
Total Weekly Tuition:*
Registration:*
Registration Fee:*
Total Due at Enrollment:*
I understand the tuition charges and agree to pay the total due at enrollment prior to my child's first day of attendance. I further understand that Tuition Express is used to process tuition payments and I will supply a valid payment method in the Electronic Funds Authorization section of this enrollment form.
Caregiver Signature*

Clear
Date*

MonthDayYear
Date
Director Signature*

Clear
Date*

MonthDayYear
To be completed by center.

Automated Payment Processing
ELECTRONIC FUNDS TRANSFER AUTHORIZATION FOR BANK ACCOUNT AND CREDIT CARD

I (we) hereby authorize Building Blocks Learning Center to initiate credit card charges to the below-referenced credit card account (Section A) OR, initiate debit entries to my (our) checking or savings account, indicated below (Section B). To properly affect the cancellation of this agreement, I (we) are required to give 10 days written notice. Credit union members: please contact your credit union to verify account and routing numbersfor automatic payments. Check with the center for accepted credit card types.
Process my payment on:*

Every Monday1st of each month15th of each month
Would you like to pay via a Credit Card or via a Bank Account?*

Credit CardBank Account
Credit Card Payment
Cardholder Name*

First NameLast Name
Cardholder Phone*
Please enter a valid phone number.
Cardholder Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Account Number*
Expiration Date*

MonthDayYear
Date
Signature*

Clear
Date*

MonthDayYear
Date
Bank Account Payment
Your Name*

First NameLast Name
Phone*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Bank or Credit Union Name*
Bank or Credit Union Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Routing Transit Number *
(see example below)
Account Number *
(see example below)
What type of account is this?*

CheckingSavings
Upload a scan or photo of a voided check.*

Cancelof
Authorized Signature*

Clear
Date*

MonthDayYear
Date
To be completed by center:
Date Received:*
To be completed by center.

Acknowledgements and Agreements

Please initial each of the following:
I understand that the facility is licensed and regulated by the New Mexico Early Childhood Education and Care Department (8.9.4 NMAC). initials*
I have read and understand the policies and procedures as specified in the Family Handbook. initials*
I have been notified that the Family Handbook is updated from time to time and will be emailed to me any time changes are made. initials*
I understand that the Family Handbook is available at http://www.tlcdevelopmentcenters.org/. initials*
I agree to always keep current contact information on file with the center. This includes my phone number, address, email address, work information, and emergency contact information. initials*
I have listed emergency contacts and authorized pick up people for my child and understand that by doing so, I am authorizing my child to be released to the persons listed at any time. initials*
I understand that any changes to people authorized to pick up my child must be submitted in writing 24 hours in advance. initials*
I understand that identification will be required before my child is released to unrecognized individuals. initials*
I understand that the center director retains the right to dis-enroll my child if my child’s needs are not being met adequately. initials*
I agree to be always respectful while on center property. initials*
I understand that any threatening or belligerent behavior on the part of my child or me may be grounds for immediate dis-enrollment. initials*
I understand that my child must be up to date on all required immunizations to be eligible to attend the center. initials*
I agree to provide a copy of my child’s immunization record each time it is updated. initials*
I understand all costs associated with my child’s attendance in the program. initials*
I agree to pay my account balance in full each month at a minimum. initials*
I understand that I am required to clock my child in and out each day through the Procare Time Clock or the Procare Engage App. initials*
I affirm that all information I have provided in this enrollment form is accurate and true to the best of my knowledge. initials*
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Building Blocks Learning Center

Child's Information

Household Information

CACFP

Household Members

Local Emergency Contacts:

Health and Developmental Questionnaire

ASQ - Consent Form

Consent for Emergency First Aide & Transportation

Consent for Medical Care and Treatment

Photo Release

Tuition Agreement

Automated Payment Processing

Credit Card Payment

Bank Account Payment

Acknowledgements and Agreements