Knox Academy LLC Enrollment Form
Please complete a new enrollment form for each child.
Child's Name:
*
First Name
Last Name
Child's Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Birthdate:
*
-
Month
-
Day
Year
Date
Gender:
*
Desired Name Tag:
What does your child prefer to be called?
Admission Date:
*
-
Month
-
Day
Year
Date
Discharge Date:
How did you hear about us?:
*
Please Select
Word of Mouth
Facebook
Instagram
Referral
School
Other
Are you interested in applying for a needs based scholarship?
*
Please Select
Yes, please send me additional information.
No, thank you.
Previous school/childcare arrangements:
*
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Identifying Information
Mother's/Guardian's Name #1:
*
First Name
Last Name
Contact Phone Number:
*
-
Area Code
Phone Number
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
E-mail Address:
*
Employer or School Name
*
Work/School Schedule:
*
Employer/School Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Employer/School Phone Number:
*
-
Area Code
Phone Number
Father/Guardian #2:
*
First Name
Last Name
Contact Phone Number:
*
-
Area Code
Phone Number
Father/Guardian #2 Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
E-mail Address:
*
Employer or School Name
*
Work/School Schedule:
*
Employer/School Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Employer/School Phone Number:
*
-
Area Code
Phone Number
Emergency Contact and Persons Authorized to Take Child from Facility (OTHER THAN A PARENT)
Please do not list a parent.
Emergency Contact #1:
*
First Name
Last Name
Relationship to child:
*
Phone Number:
*
-
Area Code
Phone Number
Emergency Contact #1 Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact #2:
*
First Name
Last Name
Relationship to child:
*
Phone Number:
*
-
Area Code
Phone Number
Emergency Contact #2 Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Child's Development
Please describe the child's development (Personal development, behavior, patterns, habits, and individual needs):
*
Please provide any medical or dietary restrictions your child may have:
*
Does your child have special behavioral needs or IEP? Please describe.
*
Do you have anything else you'd like us to know?
CACFP Requirement
Child and Adult Food Program
Related Child
*
Yes
No
Child's Relation to Child Care Provider
*
Type N/A if not related to provider
Are you of Hispanic or Latino origin?
Yes
No
What is your race? (Select one or more.)
American Indian or Alaskan native
Asian
Black or African American
Native Hawaiian or other Pacific Islander
White
Will child attend:
*
Full time
Part time
Check what days your child will attend:
*
Monday
Tuesday
Wednesday
Thursday
Friday
When does your child usually arrive each day (Mon. - Fri.)?
*
If arrival time will differ for each day, please specify.
When does your child usually leave each day (Mon. - Fri.)?
*
If arrival time will differ for each day, please specify.
Describe any changes or variations in usual attendance, including shift changes.
*
Please type N/A if there are no variations
Meals your child is usually given at Knox Academy LLC:
*
Breakfast
Morning Snack
Lunch
Afternoon Snack
Supper
Evening Snack
None
Holidays your child is in care at this facility:
*
New Year's Day
Martin Luther King, Jr.'s Birthday
Lincoln's Birthday
Washington's Birthday
Easter
Truman Day
Memorial Day
Juneteenth
Independence Day
Labor Day
Columbus Day
Veterans Day
Thanksgiving Day
Christmas Day
Authorization for Emergency Medical Care
I UNDERSTAND THAT I WILL BE NOTIFIED AT ONCE IN CASE 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 NECESSARY ARRANGEMENT, OR IN A CRITICAL EMERGENCY REQUIRING MEDICAL CARE, I AUTHORIZE KNOX ACADEMY LLC TO CONTACT THE FOLLOWING:
Physician or Clinic Name:
*
Physician or Clinic Phone Number:
*
-
Area Code
Phone Number
Preferred Hospital Name:
*
Preferred Hospital Phone Number:
*
-
Area Code
Phone Number
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Acknowledgements
Please initial next to each.
A) I have received a copy of Knox Academy LLC's policies pertaining to the admission, care, and discharge of children. I was given the opportunity to ask questions and/or voice any concerns.
*
Parent/Guardian Initials
B) I have been informed that a copy of the licensing rules for child care centers is available at Knox Academy LLC for review.
*
Parent/Guardian Initials
C) Knox Academy LLC and I have agreed on a plan for continuing communication regarding my child's development, behavior, and individual needs.
*
Parent/Guardian Initials
D) When my child is ill, I understand and agree that s/he may not be accepted for care or remain in care.
*
Parent/Guardian Initials
E) I understand that before the first day of attendance by my child, I will provide proof of age-appropriate immunizations or exemption from immunizations.
*
Parent/Guardian Initials
F) I DO 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 give permission for Knox Academy LLC to transport my child. I understand that walks on campus or around the neighborhood are a regular part of the program and I will not be notified.
*
Parent/Guardian Initials
H) I have been informed and have received a copy of the facility's safe sleep police when enrolling a child less than one (1) year of age.
*
Parent/Guardian Initials
I) I have been notified that I may request notice at initial enrollment or any time there after whether there are children currently enrolled in or attending the facility for whom an immunization exemption has been filed.
*
Parent/Guardian Initials
J) I agree to pay a fee of $2 per minute for every minute my child is picked up after 2:30 PM. There is no grace period for late pick up. This fee will be billed and must be paid on the next invoice.
*
Parent/Guardian Initials
K) I agree to hang up my cell phone before walking into Knox Academy LLC to drop off or pick up my child.
*
Parent/Guardian Initials
L) Knox Academy LLC uses the Wonderschool app for continuing communication regarding my child’s development, behavior, and individual needs. If this changes, I will be notified.
*
Parent/Guardian Initials
M) I give my consent for my child to be photographed during attendance at Knox Academy LLC. This consent releases from liability all personnel of Knox Academy LLC and any others who have received permission to take photos in the Center. This consent also gives permission for photos taken to be used in publications, shown at meetings, and/or settings where the development of children is being studied and in promotions for Knox Academy (i.e., social media, school website).
*
Parent/Guardian Initials
N) I agree to pay for every day that my child is registered and give four weeks notice before removing my child.
*
Parent/Guardian Initials
O) I acknowledge that I am responsible for tuition regardless of my child's attendance. Payments are due the first day of each month for monthly payments and on Fridays for weekly payments. Payments are due in advance of care. This payment is automatically applied to my credit card on file.
*
Parent/Guardian Initials
Payment
You will receive an invoice from Wonderschool once your enrollment form has been received. Once your enrollment form has been processed, you will receive an invoice for the $200 deposit and your first tuition payment.
Signature
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