MHPA Childcare Application

Today's Date

Proposed Start Date for Child

Child's Name*

First NameLast Name

Child's Birthdate*

Home Address*

Street Address

Street Address Line 2

CityState

Zip Code

Mailing Address (if different than home address)

Street Address

Street Address Line 2

CityState

Zip Code

MaleFemale

Current School

Current Grade

Name

First NameLast Name

Home Address

Street Address

Street Address Line 2

CityState

Zip Code

Place of Employment

Occupation

Work Address

Street Address

Street Address Line 2

CityState

Zip Code

Work Phone

Format: (000) 000-0000.

Mobile Phone

Format: (000) 000-0000.

Email

Name

First NameLast Name

Home Address

Street Address

Street Address Line 2

CityState

Zip Code

Place of Employment

Occupation

Work Address

Street Address

Street Address Line 2

CityState

Zip Code

Work Phone

Format: (000) 000-0000.

Mobile Phone

Format: (000) 000-0000.

Email

Marital Status

With whom does the child live?

Court documents

If parents are divorced or have a custodial agreement, please document custodial/visitation information. (Official court documents must be submitted with application.)

List any siblings and give their date of birth

YESNO

If you answered "YES" to the question above, please explain:

YES

Parent/Guardian Signature*

List your child's most recent school/child-care center attended (with phone number) - can list up to 3:

Please list any critical information concerning your child’s medical, psychological, or social needs that you feel we should be aware of. Also list any special needs or abilities of your child. (Fears, asthma, allergies to food or drugs)

MEDICAL INFORMATION: I authorize Morrison Heights Preschool and Afterschool to contact the physician listed below, or any other competent physician or emergency service. If I cannot be immediately contacted should my child be injured or become ill, I understand that Morrison Heights Preschool and Afterschool will not be financially responsible for medical or emergency services provided for my child. PARENT/GUARDIAN SIGNATURE*

Physician Name

First NameLast Name

Physician Phone Number

Format: (000) 000-0000.

A current 121 Form from your doctor or local Health Department must be turned in with the application. Also, any updated immunizations given after the start date will need to be turned in to the office following the day of the immunization visit. Health Department Regulations will not allow a child to enter a childcare facility without an updated immunization form. I authorize Morrison Heights to have access to these forms. PARENT/GUARDIAN SIGNATURE*

I do hereby release, acquit, discharge, and covenant to hold blameless The Morrison Heights Preschool and Afterschool, Morrison Heights Baptist Church, its’ representatives, or any attending physician, from any and all actions, damages, and liabilities, arising out of treatment of any sickness or accidents incurred by my child while in attendance with The Morrison Heights Preschool and Afterschool. It is the intent of this release to hold blameless the Morrison Heights Preschool and Afterschool and physician, of any medical need that may in their sole discretion, be needed by my child(ren) while with The Morrison Heights Preschool and Afterschool. PARENT/GUARDIAN SIGNATURE*

I authorize The Morrison Heights Preschool and Afterschool Staff to apply and/or use non-prescription lotion, diaper cream/ointment, bug spray, sunscreen, teething tablets, Orajel, or any other First Aid treatment to my child in case of minor injuries (peroxide, antibiotic ointment, Band-Aids, sting-kill, etc…). PARENT/GUARDIAN SIGNATURE*

I authorize The Morrison Heights Preschool and Afterschool to photograph and/or video my child for advertisements, web-site, newspaper, bulletin boards, art projects, end of the year video, etc.… PARENT/GUARDIAN SIGNATURE*

I authorize The Morrison Heights Preschool and Afterschool to photograph and/ or video my child for the use of posting on The Morrison Heights Preschool and Afterschool Facebook page. PARENT/GUARDIAN SIGNATURE*

I authorize my child to participate in all regularly scheduled activities, playground, or field trips sponsored by The Morrison Preschool and Afterschool. I understand that I will need to sign a permission slip for each field trip which my child participates. PARENT/GUARDIAN SIGNATURE*

I authorize The Morrison Heights Preschool and Afterschool to provide transportation for my child from school, to extracurricular activities, field trips, and as needed in emergency situations. PARENT/GUARDIAN SIGNATURE*

I declare that I understand and agree that because of limited enrollment, tuition charges are not based on attendance and there are no refunds or discounts for days missed. I also agree to give The Morrison Heights Preschool and Afterschool a written two-week notice to withdraw my child or I agree to pay for two full weeks of tuition after my child’s last day of attendance. PARENT/GUARDIAN SIGNATURE*

I declare that I understand and agree that The Morrison Heights Preschool and Afterschool is a PRIVATE CHILDCARE FACILITY and has the authority and right to deny this application for any reason other than race, sex, religion, or national origin. PARENT/GUARDIAN SIGNATURE*

I agree to the discipline policy of The Morrison Heights Preschool and Afterschool and understand that misbehavior may result in my child being excluded from certain activities and/or field trips or being removed from the program. I understand tuition is still due payable in the event of exclusion from activities and/or field trips. PARENT/GUARDIAN SIGNATURE*

In consideration of my child being permitted to participate in regular activities and activities conducted by a third party while under the care and supervision of The Morrison Heights Preschool and Afterschool, I agree to indemnify and hold harmless The Morrison Heights Preschool and Afterschool and the respective staff of the center, from all claims in any way connected with the use of the facilities or participation in third party activities of my child. PARENT/GUARDIAN SIGNATURE*

The Morrison Heights Preschool and Afterschool follows the recommendations of the American Academy of Pediatrics and the Consumer Safety Commission for safe sleep environments to reduce the risk of Sudden Infant Death Syndrome (SIDS). Our policy is that all infants will be placed on their backs in a safety-approved crib, unless a doctors written note is received requesting an alternate sleep position. Also, soft materials (blankets, pillows, stuffed toys, etc.) will not be place in the infant sleep environment. Smoking is prohibited anywhere on the property and Infants will remain lightly clothed and comfortable while sleeping. PARENT/GUARDIAN SIGNATURE*

In order to be in our 3k and 4k program the child must be fully potty trained. We define that as wearing underwear full time and child will go to the bathroom on his or her own without prompting from a teacher. PARENT/GUARDIAN SIGNATURE*

State Board of Health Regulations requires that parents be informed of the breakfast policy of a childcare facility. Furthermore, the administrative staff and teachers of The Morrison Heights Preschool and Afterschool would like to make certain that each parent understands that our morning snack is not intended to be a breakfast meal. (IT IS ONLY A SNACK). PARENT/GUARDIAN SIGNATURE*

I have received a copy of the Parent Handbook and a copy of the Mississippi State Department of Health Regulation Summary for Parents. I have read both of these and understand the contents of each. PARENT/GUARDIAN SIGNATURE*

I declare that I understand and agree to the charges (late pick-up, late payment, no call policy, returned check, tuition, fees and the following policy of The Morrison Heights Preschool and Afterschool.) Failure to pay account balances in a timely manner will result in the dismissal of my child from The Morrison Heights Preschool and Afterschool and I agree to pay all charges DUE on my account at this time. PARENT/GUARDIAN SIGNATURE*

I authorize The Morrison Heights Preschool and Afterschool to provide transportation for my School age child from school to the childcare facility and other activities away from the Center. I also agree to a $10.00 courtesy call fee if I fail to notify The Morrison Heights Preschool and Afterschool that my child WILL NOT be riding the bus from school. PARENT/GUARDIAN SIGNATURE*

I understand that when/if an opening becomes available for my child/children I will be contacted by phone and/or email. I will then have 24 hours to accept or decline the positon. If I chose to accept the spot, I will have to begin paying tuition on a Monday no later than 2 ½ weeks after accepting the spot. If I choose to decline the position I will be removed from the waiting list. ($50.00 application fee is non-refundable). PARENT/GUARDIAN SIGNATURE*

The Morrison Heights Preschool and Afterschool hours are from 7:00am-6:00pm. This means that all children should be gone from the center by 6:00pm. Parents should be prompt picking their child(ren) up, considering the time it will take to pick up their child for the center to CLOSE at 6:00pm. There is a charge of $1.00 per minute after 6:05pm. If an emergency arises and you are unable to pick up your child by 6:00pm, please contact the office IMMEDIATELY. PARENT/GUARDIAN SIGNATURE*

YES

Child Name

First NameLast Name

Parent Printed Name

First NameLast Name

Parent Signature*

Date

Child's Name

First NameLast Name

Child's Birthdate

Mother's Name

First NameLast Name

Mother's Mobile Phone

Format: (000) 000-0000.

Employer Phone

Format: (000) 000-0000.

Mother's Email

Father's Employer

Employer Phone

Format: (000) 000-0000.

Mother's Employer

Father's Name

First NameLast Name

Father's Mobile Phone

Format: (000) 000-0000.

Father's Email

First 4 People to Contact (list in order of priority) - Describe their relationship to the child and give their phone number.

Physician to be called in case of an emergency

First NameLast Name

Physician's Phone Number

Format: (000) 000-0000.

List the people that CAN pick up your child at ANY time. (Do not list parents or emergency contacts from above unless they cannot pick up the child - then list them below.)

List the people that CANNOT pick up your child at ANY time.

List any allergies and/or critical information.

In the event that I cannot be readily be located and there arises an emergency necessitating medical attention, I hereby consent and give my permission (to The Morrison Heights Preschool and Afterschool, Morrison Heights Baptist church, its representatives, or any attending physician,) to make such decisions and to provide such medical treatments upon my child which may in their sole discretion be necessary and proper under the circumstances. PARENT/GUARDIAN SIGNATURE*

Application for Child Care

Child's Information

Father's Information

Mother's Information

Family Information

Emergency Card