Phase II Academy Enrollment Form

Child Care Enrollment Form

Missouri Department of Elementary and Secondary Education, Office of Childhood – Child Care Compliance
Facility/Provider Name:
Admission Date
Discharge Date
Child's Name
Gender
Birthdate

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Child’s Address

Section 2: Identifying Information
Parent/Guardian Name

First NameLast Name
Telephone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address
Check if same as child’s address
Email Address
Employer or School
Work/School Schedule
Employer/School Address
Work Telephone Number
Parent/Guardian Name

First NameLast Name
Telephone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address
Check if same as child’s address
Email Address
Employer or School
Work/School Schedule
Employer/School Address
Work Telephone Number

Section 3: Emergency Contact
Emergency Contact and Persons Authorized to Take Child from Facility Other Than Parent (At Least One Emergency Contact Is Required)

Section 4: Comments on Child’s Development
Comments on Child’s Development (Personal Development, Behavior, Patterns, Habits, & Individual Needs).

Section 5: Related Child
Related Child
Child’s Relation to Child Care Provider.

Section 6: Ethnic and Race Information
Are you of Hispanic or Latino origin?
What is your race? (Select one or more.)

Section 7: Child’s Attendance Schedule
Will child attend?
Child’s Projected Attendance Schedule and Any Variations Expected

Section 8: Meals Provided
Meals Your Child Is Usually Given at This Facility

Section 10: Emergency Medical Care Authorization
I understand that I will be notified at once in the event of an emergency with my child, and I will make arrangements for medical care of my child with the physician or hospital of my choice. If I cannot be reached to make the necessary arrangements, or in a critical emergency requiring medical care, I authorize:

Phase II Academy
Child Care Facility Name
Physician or Clinic Name

First NameLast Name
Telephone Number
Please enter a valid phone number.Format: (000) 000-0000.
Preferred Hospital Name
Preferred Hospital Telephone Number
Please enter a valid phone number.Format: (000) 000-0000.

Section 11: Acknowledgments
Please read and acknowledge each statement by entering your initials. Complete the signature and date fields at the end of this section.
A. I have received a copy of this facility’s policies pertaining to the admission, care, and discharge of children.
B. I have been informed that a copy of the licensing rules for child care home or the licensing rules for group child care homes and centers is available at this facility for review.
C. The provider and I have agreed on a plan for continuing communication regarding my child’s development, behavior, and individual needs.
D. When my child is ill, I understand and agree that s/he may not be accepted for care or remain in care.
E. I understand that, before the first day of attendance by my child, I will provide proof of completed age-appropriate immunizations or exemption from immunizations.
F. I do / do not give permission for field trips/excursions. I understand that I will be notified in advance when they are planned.
Parent/Guardian Initials
G. I do / do not give permission for the facility to transport my child.
Parent/Guardian Initials
H. I have been informed and received a copy of the facility’s safe sleep policy when enrolling a child less than one (1) year of age.
I. I have been notified that I may request notice at initial enrollment or at any time thereafter whether there are children currently enrolled in or attending the facility for whom an immunization exemption has been filed.
Parent/Guardian Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Which annual update is this for?
First Annual Update
First Annual Update - Parent/Guardian Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Second Annual Update
Second Annual Update - Parent/Guardian Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Third Annual Update
Third Annual Update - Parent/Guardian Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

USDA Nondiscrimination Statement

In accordance with federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, this institution is prohibited from discriminating on the basis of race, color, national origin, sex (including gender identity and sexual orientation), disability, age, or reprisal or retaliation for prior civil rights activity.

Program information may be made available in languages other than English. Persons with disabilities who require alternative means of communication to obtain program information (e.g., Braille, large print, audiotape, American Sign Language) should contact the responsible state or local agency that administers the program or USDA’s TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339.

To file a program discrimination complaint, a Complainant should complete a Form AD-3027, USDA Program Discrimination Complaint Form which can be obtained online at: https://www.usda.gov/sites/default/files/documents/ad-3027.pdf , from any USDA office, by calling (866) 632-9992, or by writing a letter addressed to USDA. The letter must contain the complainant’s name, address, telephone number, and a written description of the alleged discriminatory action in sufficient detail to inform the Assistant Secretary for Civil Rights (ASCR) about the nature and date of an alleged civil rights violation. The completed AD-3027 form or letter must be submitted to USDA by:

1.Mail:
U.S. Department of Agriculture
Office of the Assistant Secretary for Civil Rights
1400 Independence Avenue, SW Washington, D.C. 20250-9410

2.Fax:
(833) 256-1665 or (202) 690-7442

3.Email:
program.intake@usda.gov

This institution is an equal opportunity provider.
Should be Empty: