Under the Magic Pine Tree Enrollment Application

A Reggio Inspired School

927 Mitch Dr Gardnerville NV 89460 775-265-2023
Enrollment Application
Child's Name:*
Birthdate:*

MonthDayYear
Date
Start Date:*

MonthDayYear
Date
Mailing Address:*
City:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
State:*
Zip:*
Home Address:*
City:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
State:*
Zip:*
Fathers Name:*
Social Security:*
D/L #:*
Home Address:*
Employer Name:*
Employer Address:*
Email Address:*
example@example.com
Work Telephone:*
Home Telephone:*
Mother's Name:*
Social Security:*
D/L #:*
Home Address:*
Employer Name:*
Employer Address:*
Email Address:*
example@example.com
Work Telephone:*
Home Telephone:*

AUTHORIZED TO PICK UP (Must be 18 or older)*

	Name	Address	Phone	Relationship
1
2
3

Contracted Schedule - Please list your child's drop off and pick up times * Please note we do not offer care for varied schedules.*

	Monday	Tuesday	Wednesday	Thursday	Friday
Time

Please initial the following:
If parent(s) or above authorized persons are unreachable in an emergency, I authorize Under the Magic Pine Tree to have my child transported to a local hospital and I agree to pay for any services rendered or any necessary treatment resulting from emergency care.*

Clear
I hereby grant permission for my child to use all play equipment and participate in all activities at Under the Magic Pine Tree.*

Clear
I hereby grant permission for my child to be included in evaluations and pictures in connection with school programs and the center’s Procare parent communication app.*

Clear
I hereby acknowledge that I have read and understand Under the Magic Pine Tree’s billing process and requirements and agree to adhere to the rules, regulations and policies and further understand that tuition fees are based on a weekly rate and are not dependent upon attendance or closures. I also understand no credits will be given.*

Clear
Hours and days not scheduled and added will be billed as additional and are on a “space available” basis.*

Clear
I understand that UTMPT requires that all children are dropped off by 10am.*

Clear
Signature* I (we) agree to enroll my (our) child blanks*in Under the Magic Pine Tree Childcare Center.
Signature* My child will be enrolled in the blanks* classroom and my weekly tuition is Type a label*.
Signature* I understand that there is a registration fee of blanks* that is non-refundable and a supply fee of blank* that is billed every January and June.
Signature* I am currently receiving tuition assistance through blanks*. My caseworker isblank* and their contact number is Type a label*. I understand UTMPT must receive authorization prior to starting at UTMPT.
I (we) have received and read Under the Magic Pine Tree’s Parent Handbook and understand the rules and regulations and policies stated therein. I (we) agree to adhere to all policies set forth by the Center . If my child (children) is on Children’s Cabinet or other assistance program, I understand I am responsible for what the program does not pay and must make a weekly payment equal to my co-pay. I understand all unpaid balances will be sent to a collection agency for collections actions.

I understand if I have an unpaid balance to Under the Magic Pine Tree and do not make satisfactory payment arrangements, my account may be placed with an external collection agency. I will be responsible for reimbursement of the fee of any collection agency, which may be based on a percentage at a maximum of 35% of the debt, and all costs and expenses, including reasonable collection and attorney’s fees incurred during collection efforts.

In order for Under the Magic Pine Tree or their designated external collection agency to service my account, and where not prohibited by applicable law, I agree that Under the Magic Pine Tree and the designated external collection agency are authorized to (i) contact me by telephone at the telephone number(s) I am providing, including wireless telephone numbers, which could result in charges to me, (ii) contact me by sending text messages (message and data rates may apply) or emails, using any email address I provide and (iii) methods of contact may include using pre-recorded/artificial voice message and/or use of an automatic dialing device, as applicable.

No exceptions will be made to the center’s policies in the parent handbook or any of the program fees in the rate sheet.

Any questions or concerns will be addressed by the Director either in person or by email. UTMPTHawthorne@gmail.com

I have read and understand the policies outlined in the UTMPT Parent Handbook and agree to the terms. I understand both myself and Child Care Licensing will be notified of any changes made to the policies in this contract.
Signature of Parent or Guardian:*

Clear
Date:*

MonthDayYear
Date
Signature of Parent or Guardian:*

Clear
Date:*

MonthDayYear
Date

If your child's medical history includes any of the following, please note the age when the incident or illness occurred and any other pertinent information:
Childhood Illness:*
Hospitalizations:*
Seizures/Convulsions:*
Eye Problems:*
Allergies:*
Operations:*
Seizures with fever:*
Wheezing:*
Appetite/Bowels:*
Head Injuries:*
Ear Problems/Hearing Loss:*
Sleep Problems:*
What precautions or treatments are done for any of the above (please include any allergies):*
Is there a court order affecting this child?*
Yes/No. If yes, parent/guardian must provide a certified cop of court order before child may attend program. If not, please be aware that as per the law, both parents will be afforded immediate access to the child. Please refer to parent handbook for further explanation of this policy or speak with center director.
Does the child have special needs?*
Please list any social, emotional, behavioral, or learning disabilities, medical requirements, food or environmental allergies, and/or IEP's:*
UTMPT complies with all laws and regulations regarding servicing children with special needs including but not limited tothe Americans with Disabilities Act. UTMPT will provide reasonable accommodation for those children who have adocumented disability and whose parents work closely with UTMPT to determine a reasonable accommodation.
This form has been completed by (print name):*
Signature:*

Clear
Date:*

MonthDayYear
Date
Email:*
example@example.com

UTMPT Gardernville Rate Sheet

The following rates apply based on your weekly contracted schedule which is submitted upon registering your child with Under the Magic Pine Tree. All children attending must be registered prior to their start date. Any time over 4 hours will be considered a full day and will be billed as such. Care is paid weekly whether your child attends or not. No refunds or credits are given. UTMPT only accepts ACH auto payments through Tuition Express.
Tuition is due on the Friday prior to the week of care.

Registration fee is $95. A supply fee of $50 is paid twice a year in January and June.
* Preschoolers are children who are in the preschool classroom.

Late pick up fees: $15/child for the first 0-5 minutes and $1 per minute thereafter. Late fees will be added to your tuition bill and will be due with the next tuition payment.

I/We do hereby understand and accept responsibility for any and all charges incurred that include, but is not limited to, fees for late payments, NSF checks, late pickups, etc. I/We agree to abide by the terms of this Financial Contract and the Under the Magic Pine Tree’s Parent Handbook as they relate to my/our child. I further understand that rates can be changed at any time. By Signing below, I/We do hereby acknowledge our receipt of the school parent handbook and do hereby understand that I am responsible for reading and abiding by the rules outlined in Under the Magic Pine Tree’s Parent Handbook. I further understand that rates are subject to change at any time and when my child moves to a new classroom, rates will be updated to reflect the center’s current rate schedule for that classroom.
Printed Name:*
Parent Signature:*

Clear
Date:*

MonthDayYear
Date
Printed Name:*
Parent Signature:*

Clear
Date:*

MonthDayYear
Date

Permission to Release Information
I understand that the time my child, blanks* is in the facility, that the director may be asked for information regarding my child.
I herby give permission to release information to official persons only, who identify themselves, such as schools, health care professionals, welfare or other government officials. *

Clear
I do not give my permission to release any information about my child as set forth in the aforementioned statement. I understand that the Bureau of Services for Child Care has access to my child's record as the licensing agent and may view the record upon BSCC facility inspection.*

Clear
Signature of enrolling Parent/Guardian:*

Clear
Date:*

MonthDayYear
Date
Transportation Form/Field Trip Permit
I understand my child may take part in field trips and educational excursions, however these trips are not onsite and UTMPT does not transport children.*

Clear
(Provider's name) blanks* may transport my child, Type a label* in the event of an emergency evacuation or disaster preparedness drill of the facility.
Signature of enrolling Parent/Guardian:*

Clear
Date:*

MonthDayYear
Date
Parental Right to Review Facility Substantiated Complaints
I, Type a label* , (Parent/Guardan) am aware that I have the right to request and review any complaints the facility has received within the last 12 months of my child's(ren's) enrollment.
Signature of enrolling ParentGuardian*

Clear
Date*

MonthDayYear
Date

Consent for Medical Treatment

Parent/Guardian agrees the provider may consult with the child's nurse or attending physician regarding child's health as needed. If we should have questions regarding the health of the enrolling child, we may contact one, or more, of the following sources for information.
Hospital of Choice and Phone Number:*
Doctor Name:*
Address:*
Phone Number:*
In an emergency, I blanks*, (Parent/Guardian), give my authorization to, Under the Magic Pine Tree and its staff, and my local physician, dentist, or hospital to provide medical care and/or transport my child at my expense.
Medical Plan:*
Policy Number:*
Phone Number:*
Does your child require additional accommodations?*

YesNo
Explain:*
Are the problems serious enough to restrict our child activities?*

YesNo
Explain:*
Describe, if any, special care required:*
Does your child get frequent colds?*

YesNo
List any allergies staff should be aware of:*
Is your child currently taking prescribed medication?*

YesNo
Name of medication(s):*
If yes, for what reason?*
Parent Signature:*

Clear
Date:*

MonthDayYear
Date

Parental Consent Form for Sunscreen Application
Date:*

MonthDayYear
Date
Name of Child:*
As the parent of guardian of the above child, I recognize that too much sunlight may increase my child's risk for skin cancer later in life. Therefore, I give my permission for the staff of Under the Magic Pine Tree to apply Rocky Mountain Sunscreen SPF 50 to my child as specified below, when he or she will be playing outside during the months of April to October and between the hours of 11am and 4pm.

I understand that I must apply sunscreen on my child prior to them arriving at UTMPT for the day and that UTMPT will apply the second application. I further understand that sunscreen may be applied to exposed skin including but not limited to the face, tops of the ears, nose, bare shoulders, arms and legs.

I have checked below all applicable information regarding the type and use of sunscreen for my child.
I have consulted with my child’s physician and do not know of any allergies or allergic reactions my child may have to Rocky Mountain Sunscreen SPF50.*

Clear
I give my permission for the UTMPT staff to apply Rocky Mountain SPF50 to my child as descrived above.*

Clear
For medical reasons DO NOT apply sunscreen to my child under any circumstances.*

Clear
Parent/Guardian Full Name (Please Print):*
Parent/Guarding Signature:*

Clear

General Photography Release
I hereby authorize Under the Magic Pine Tree to publish photographs taken of me/my child, and my name and likeness, for use in the Under the Magic Pine Tree print, online and video-based marketing materials, as well as other company publications.

I hereby release and hold harmless Under the Magic Pine Tree from any reasonable expectation of privacy or confidentiality associated with the images specified above.

I further acknowledge that my participation is voluntary and that I will not receive financial compensation of any type associated with the taking or publication of these photographs or participation in company marketing materials or other company publications. I acknowledge and agree that publication of said photographs confers no rights of ownership or royalties whatsoever.

I hereby release Under the Magic Pine Tree, its contractors, its employees, and any third parties involved in the creation or publication of marketing materials, from liability for any claims by me or any third party in connection with my participation.

*Please note that all children are photographed and shared with all families enrolled at our center through our Procare App. You cannot opt out of this policy but can choose to attend another center should you not agree to this policy.
I agree to all photo policies at Under the Magic Pine Tree:*

Clear
Printed name:*
Signature:*

Clear
Date:*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Automated Payment Processing

Safe. Convenient. Easy.
We are excited to offer the safety, convenience and ease of Tuition Express®—a payment processing system that allows secure, on-time tuition and fee payments to be made from either your bank account or credit card.

ELECTRONIC FUNDS TRANSFER AUTHORIZATION FOR BANK ACCOUNT AND CREDIT CARD

I (we) hereby authorize Under The Magic Pine Tree 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 numbers for automatic payments. Check with the center for accepted credit card types.
Name*

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

Street Address Line 2

CityState / Province

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

Street Address Line 2

CityState / Province

Postal / Zip Code
Routing Transit Number (see sample below):*
Account Number (see sample below):*
Account Type:*

CheckingSavings
Authorized Signature:*

Clear
Date*

MonthDayYear
Date
Should be Empty:

A Reggio Inspired School

Enrollment Application

Family Information Form

If your child's medical history includes any of the following, please note the age when the incident or illness occurred and any other pertinent information:

UTMPT Gardernville Rate Sheet

Permission to Release Information

Transportation Form/Field Trip Permit

Parental Right to Review Facility Substantiated Complaints

Consent for Medical Treatment

Parental Consent Form for Sunscreen Application

General Photography Release

Automated Payment Processing