Child care Application and enrollment Form

Child care Application and enrollment Form
Student Enrolment Application Form Thank you for your interest in our school. Please click 'Next' to continue.
Location (Choose One)

Rosa Old West Tampa - 1802 N Albany (Infant - 5 years old)Rosa @ Oak Grove - 2707 W Waters Ave (Infant - 12 years old)

Section 1: Student information
Student Details
Name

First NameMiddle NameLast Name
Preferred name
Date of birth

DayMonthYear
Date
Current Date

MonthDayYear
Date
Gender

FemaleMale
AGE
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Section 2: parent/Guardian 2 information
Parent/Guardian 2
Name*

TitleFirst NameMiddle NameLast Name
Preferred name
Legal custody status to child*

MotherFatherOther (please specify)
Other legal custody status to child*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Mobile phone*
Home phone
Employer or School attending
Employer of School attending
If applicable
Address Employer or School attending
If applicable
Work phone

Section 3: PERSONS AUTHORIZED TO REMOVE THE CHILD FROM THE CENTER - MUST BE 18 YEARS OF AGE WITH VALID ID

YOU MAY ADD UP TO (4) AUTHORIZED PERSONS TO REMOVE THE CHILD FROM THE CENTER
Authorized name *

TitleFirst NameLast Name
Relationship*
Phone Number*
Please enter a valid phone number.
Do you wish to add another authorized person to remove the child from the center?

YesNo
Authorized name *

TitleFirst NameLast Name
Relationship*
Phone Number*
Please enter a valid phone number.
Do you wish to add another authorized person to remove the child from the center?*

YesNo
Authorized name *

TitleFirst NameLast Name
Relationship*
Phone Number*
Please enter a valid phone number.
Do you wish to add another authorized person to remove the child from the center?*

YesNo
Authorized name *

TitleFirst NameLast Name
Relationship*
Phone Number*
Please enter a valid phone number.

Section 5: EMERGENCY MEDICAL RELEASE

In case of an emergency, the following people are also authorized to remove the child from the facility and arrange for emergency treatment in my absence.
Emergency contacts (other than caregivers)
Contact 1 name

TitleFirst NameLast Name
Phone number
Relationship to child
Contact 2 name

TitleFirst NameLast Name
Phone number
Relationship to child
Doctor Informtion

Should the facility be unable to reach me and/or the persons designated, they are authorized to contact my child's physician and/or arrand for immediate emergency medical treatment and transportation as necessary.

The physician, emergency medical personnel, and/or the medical facility are authorized to transport and administer emergency medical treatment necessary to ensure the health and safety of my child. I will accept responsibility for payment for all services rendered.
My child has the following medical alert information (allergies, medical, and/or handicapping conditions) that they need to know about: (write NONE if none)*
Preferred Physician full Name
Preferred Hospital
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone number*
ALTERNATE NUTRITION PLAN AGREEMENT

I understand and approve the use of the Alternate Nutrition Plan. I agree to provide the following meals and/or snacks to meet my child's nutritional and dietary needs.
Indicate any Special Dietary Requirements ( if non, enter NONE)*
Who will provide Special Dietary Requirements?*

CenterParentNot Applicable
BreakfastAM SnackLunchPM SnackFormula
HILLSBOROUGH COUNTY ORDINANCE requires that parents must receive a copy of the "KNOW YOUR CHILD CARE FACILITY /FCCH BROCHURE," information on the INFLUENZA (FLU) VIRUS, information on "DISTRACTIVE DRIVER," AND "RILYA WILSON ACT," and the parents are notified in writing of the "DISCIPLINARY PRACTICES" and "EXPULSION POLICY" used by the Child Care Facility/FCCH. The parent's/legal guardian's signature certified receipt of the Child Care Facility/FCCH brochure, influenza information, discipline policies, alternate nutrition plan agreement, and that all the information on this form is complete and accurate.
Parent / Guardian Signature*

Clear
Date

MonthDayYear
Date

Section 6: PAYMENT FOR SERVICES CONTRACT
School fees

ENROLLMENT FEES
NEW CHILD	$25.00
ADDITIONAL CHILD	$15.00
RE-ENROLLMENT	$10.00
ADDITIONAL CHILD	$5.00

WEEKLY RATES	FULL TIME WEEKLY	PART-TIME WEEKLY
INFANTS	$210.00	$180.00
TODDLERS	$184.00	$155.00
TODDLER -2	$170.00	$150.00
3 YEAR OLD PRESCHOOL	$140.00	$120.00
4-5 YEAR OLD PRESCHOOL NON VPK	$135.00	$115.00
VOLUNTARY PRE-KINDERGARDEN (WITH vpk VOUCHER	N/A	$115.00
5 YRS OLD IN SCHOOL	$135.00	$115.00

AFTER SCHOOLERS - OAK GROVE LOCATION ONLY	$115.00
FALL / WINTER / SPRING BREAK	$135.00
SCHOOL AGE NEXTGEN LEADERS SUMMER CAMP	$220.00

SCHOOL AGE NEXTGEN LEADERS SUMMER CAMP 4 WEEK PACKAGE	$720.00
SCHOOL AGE NEXTGEN LEADERS SUMMER CAMP 8 WEEK PACKAGE	$1400.00

Please choose *
Estimated Weekly Payment
School Readiness rates (for those who qualify) are issued by the Early Learing Coalition. In-house tuition assistance (for children already enrolled) is available for those who qualify; please see the center manager to complete an application.

Tuition Policy: All tuition is due EVERY FRIDAY BEFORE the start of the next week. Tuition for the upcoming week is billed on Thursday and MUST be paid completely on Friday. In order to drop off on Monday, your tuition account MUST be at zero balance and ready to be billed again on Thursday for the next upcoming week.

Hours of Operation: Our center is open from 7:00AM until 6:00 PM Monday through Friday. Administrative hours are 8:00AM until 5:45PM Monday through Friday.
VPK Hours (choose one)*

Full-TimePart-Time
Funding Sources - Choose all that apply*

VPK voucherSchool Readiness voucherPrivate Pay
VPK File Upload*

Please ensure each file upload is smaller than the limit of 5MB
Cancelof
School Readiness File Upload*

Please ensure each file upload is smaller than the limit of 5MB
Cancelof
Parents School Readiness Contract Co-Pay
Parents Weekly Private Payment
Section 7: Consent and agreement

Consent and agreement are provided for the duration of the student’s enrolment. Any changes need to be notified in writing.
I understand and agree to pay for services according to the policy stated in the enrollment packet.
i agree to pay all fees due on Friday before attendance each week in advance. I understand that my child may not attend unless all fees are paid. Payments must be made on the website www.cornerstonefamilyministries.org. Payments not received will be reported to each funding source which will place the parent's contract in jeopardy of being terminated.

Yes, I Understand and Agree
A nonrefundable NSF fee of $25.00 will be charged to all accounts that bounce a check. Checks will no longer be accepted after the second bounced check.

Yes, I Understand and Agree
No credit will be given for days the center is officially closed or when the child is absent or suspended for any reason. Parents are charged for a slot as opposed to the days the child attends.

Yes, I Understand and Agree
Other arrangements and agreements (if none, write NONE)*
My signature below indiecates that I have read and agree to the terms of this contract, pending final fee and payment verification from center director. It further indicates that I have had the center's policy regarding payment of fees explained to me and that all of my questions have been satisfactorily answered.
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Child care Application and enrollment Form

Section 1: Student information

Section 2: PARENT/GUARDIAN information

Section 2: parent/Guardian 2 information

Section 3: PERSONS AUTHORIZED TO REMOVE THE CHILD FROM THE CENTER - MUST BE 18 YEARS OF AGE WITH VALID ID

Section 5: EMERGENCY MEDICAL RELEASE

Section 6: PAYMENT FOR SERVICES CONTRACT

Section 7: Consent and agreement