2025 LC Enrollment Form

My Little Planet Learning Center Enrollment Form

316 S. Auburn St. Kennewick WA 99336
Dear Parent/Guardian,

Thank you for your interest in enrolling your child at My Little Planet Learning Center! We are excited about the opportunity to partner with you in your child’s growth, learning, and development.

To ensure a smooth enrollment process, please complete the following steps in the order listed below. Applications will not be processed until all steps are completed:
1. Submit a completed application – The application must be filled out in full and returned to our office.
2. Provide a WA State Certificate of Immunizations (CIS) – The CIS must be marked as “Complete” according to Washington State requirements.
3. Set up a payment arrangement –
  - Private Pay (Out-of-Pocket): A non-refundable $95 processing fee is required, along with payment for the first two (2) weeks of care in advance.
  - Subsidized Childcare (DSHS): We must receive a valid Letter of Authorization from DSHS before your child can begin care. Our provider# is 082287
4. Schedule a One-on-One visit – This allows your child to meet their future classmates and teachers prior to their first day.
Please note: We require at least one (1) business day to process applications once all the above steps have been completed. Applications submitted with missing information or documents will be placed on hold until all requirements are met.

We also offer tours for parents who would like to see our classrooms and meet our staff. While tours are available, they are not required for enrollment.

We look forward to welcoming your child into our program! If you have any questions or need assistance with the application process, please contact us at 509-582-7301 or mylittleplanetdcc@gmail.com.

Warm regards,

Ana Samaniego

OwnerIDirector
My Little Planet Learning Center & Early Education Academy

Child Registration Form

Child's Information
Name*

First NameMiddle NameLast Name
Child's Nick Name
Birthdate*

MonthDayYear
Date
Sex*
M-Male F-Female
Age*
Child's Primary Language*
Parent/ Guardian/ Sponsor Primary Language*
Child's Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Does your child attend school?*

YesNo
School Name*
Grade*
School Phone*
Please enter a valid phone number.
School Address*
Please note My Little Planet does not provide transportation to or from school. The Kennewick School District may be able to arrange a bus route, you would need to contact them.
Bus Drop Off Time*

Hour Minutes

AM/PM Option
Bus Pick Up Time*

Hour Minutes

AM/PM Option
Family Information

Parent/ Guardian #1
Parent/ Guardian/ Sponsor*

First NameLast Name
Relationship to Child*
Home Phone*
Please enter a valid phone number.
Cell Phone*
Please enter a valid phone number.
Please enter the name of your phone company. (for text mesages)
Example: T-Mobile
Home Address *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Email*
example@example.com
Work Email
example@example.com
Work Phone
Please enter a valid phone number.
Employer
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Work Hours

Parent/ Guardian #2
Parent/ Guardian/ Sponsor 2

First NameLast Name
Relationship to Child
Home Phone Number
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Email
example@example.com
Work Email
example@example.com
Employer
Work Phone Number
Please enter a valid phone number.
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Work Hours

Child/ Family History
My Little Planet Learning Center is committed to providing a safe, positive, and engaging experience for every child. To support this, we ask parents/guardians to share any helpful information about their child
Child's Pets*
Child's Favorite Activities*
Child's Favorite Toy*
Child's Favorite Food & Drink*
Child is frightened by:*
Child is self-soothed by:*
Please describe your child's morning routine before arriving at childcare*
Please list all persons living with the child & relationship*
Please describe any previous experience your child has in child-care*
Is there a court order affecting this child?*

YesNo
If yes, parent/ guardian must provide a certified copy of court order before child may attend program. If no, please be aware that as per the law, both parents will be afforded immediate access to the child. Please refer to the parent handbook for further explanation of this policy or speak with the center director.

Child Emergency Contact & Release Information

(Do not include parents/guardians/sponsors)
Please notify the center if an Emergency Release Contact will pick up your child on a given day.***

For the safety of your child, we request that all authorized pick-up persons with whom staff is not familiar provide a photo ID at the time of pickup.

Emergency Contact #1
Name*
Relationship to child*
Home Phone
Please enter a valid phone number.
Cell phone*
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home email
example@example.com
Work email
example@example.com
Work phone
Please enter a valid phone number.
Employer
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Work hours

Emergency Contact #2
Name
Relationship to child
Home phone
Please enter a valid phone number.
Cell phone
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home email
example@example.com
Work email
example@example.com
Work phone
Please enter a valid phone number.
Employer
Employer address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Work hours
Person #3

Emergency Contact #3
Person #3 Name
Relationship to child
Home Phone Number
Please enter a valid phone number.
Cell phone number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home email
example@example.com
Work email
example@example.com
Work phone
Please enter a valid phone number.
Employer
Type a question
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Work hours

Complete & Sign
Completion of this agreement is required for enrollment. This form will enable us to better understand your child and meet his/her needs. Much of the information requested is necessary to comply with state childcare licensing regulations.The persons designated in this section will be contacted by us if you cannot be reached in the event of a medical or another emergency. Our staff will only release your child to you or to those persons listed above. If you want a person who is not identified above to pick up your child, you must notify our staff in advance, in writing. Your child will not bereleased without prior authorization.
Signature*

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Date*

MonthDayYear
Date

Childcare Agreement Form
* Hours of Operation

Regular operating hours are 6:00am- 6:00 pm except for closings for various holidays, and inclement weather as described in the Family Handbook. Please consult the current calendar for holidays. There is no reduction in tuition as a result of center closures.

The procedure to notify families should severe weather or other conditions prevent the programf rom opening on time or at all will be announced on Facebook-Email- Text. If it becomes necessary to close erly, we will contact you or someone listed in the emergency contact and release, and it i will be your responsobilitiy to arrange for your child's early pickup.

Schedule Attendance
The days and hours that I wish to contract for childcare are as follows.

(For days not attending, start time and end time should both be 8:00AM)
Monday Start Time*

Hour Minutes

AM/PM Option

Until
until
Hour Minutes

AM/PM Option
Tuesday Start Time*

Hour Minutes

AM/PM Option

Until
until
Hour Minutes

AM/PM Option
Wednesday Start Time*

Hour Minutes

AM/PM Option

Until
until
Hour Minutes

AM/PM Option
Thursday Start Time*

Hour Minutes

AM/PM Option

Until
until
Hour Minutes

AM/PM Option
Friday Start Time*

Hour Minutes

AM/PM Option

Until
until
Hour Minutes

AM/PM Option
Comments
I Would prefer to make tuition payments on a:*

Weekly BasisBi-Weekly BasisMonthly Basis
**For child care subsidy select "Monthly- Basis".

Fee Policy
The exact tuition fee agreement is to be completed by staff , then reviewed and initialed by the parent/ guardian in person.

Starting on __________ the following fee is due every week.

$345 Preschool- Full Time

$290 Preschool- 4 Days

$255 Preschool- 3 Days

$325 Summer

$___ Extra Supervision



$210 School Age- AM & PM

$195 School Age- AM Only

$175 School Age- PM Only

$310 School Age- All Day

$___ Extra Supervision

Tuition is due and payable by:

___Every Friday

___ The 1st and 15th of the month or the next business day.

___ The 1st business day of the month.
- Tuition is not subject to discounts for holidays, emergency closures (i.e., wheather or pandemic) or absenes other than hospitalization, or absence at the request of a dcotor (a written doctor's note is required to receive credit).
- I agree to pay the full tuition in advance of service rendered.
- I agree to pay the full tuition fee even if my child is absent for one or more days.
Please read the following and then initial. These apply to all parents regardless of form of payment.
- A late fee of $25 is due if tuition is not received on time.
- A non-refundable registration fee of $95 is due yearly. (if receiving state assistance, DSHS will cover this cost)
- A late pick up fee of $3 per minute after 6:00 PM, per child will be applied (not to exceed $160 per child) This fee is due if my child is not picke dup before closing time, 6PM, or after agreed upon full time part time schedule.
- Accounts that are two weeks in arrears may result in immediate termination of service.
- My child may have the opportunity to participate in a special program or field trip that may have an additonal fee due before the day of the event. A specific permission slip may be required.
- All returned ACH transactions (automatic debits) will be charged a fee of $35.00. Two or more returned ACH transactions will result in my account being placed on "money order only" status.
- A two-week written notice is required for any child being withdrawn from the program. Failure to providde notice in writting will result in forfeiture of deposit.
Initial here

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Medical Consent & Provider Information Form

Health Care Provider
Primary Physician's Name*
Primary Physician's Practice Name*
Primary Physician's Phone Number*
Please enter a valid phone number.
Primary Physician's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Preferred Hospital Emergency Care*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of child's last physical exam*

MonthDayYear
Date
Dentist's Name*
Dentist's Practice Name*
Dentist's Phone Number*
Please enter a valid phone number.
Dentist's Practice Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Child's Insurance Provider
Health Insurance Provider Name*
Policy Number*
Secondary Insurance Provider Name
Policy Number

Emergency Medical Authorization & Consent
Please read the following and initial.
- In case of a medical emergency, the staff will attempt to contact me, those listed in the Child Emergency Contact and release, and lasty my physician.
- In case of a medical emergency, I agree that my child may receive first aid and/or CPR.
- In case of a medical emergency, I permit the transportation of my child to a local hospital or another urgent care facility, if necessary, by paramedics or other emergency personnel.
- In case of a medical emergency, I will be responsible for the emergency medical expenses.
- In case of an accidental ingestion fo a pooisonous substance, I consent to my child being treated as directed by the Poison Control Center.
Initial here*

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Does child have an Individual Health Plan?*

YesNo

Medical Consent
I give permission that my child, Child's Name , may be given first aid/ emergency treatment by the childcare licensee and/ or qualified staff at My Little Planet Learning Center, 316 S. Auburn St. Kennewick, WA 99336.
When I cannot be contacted, I authorize and consent to medical, surgical, and/or hospital care, treatment, and procedures to be performed for my child by a licensed physician, health care provider, hospital, or aid care attendant, when deemed necessary or advisable by the physician or aid care attendant to safeguard my child's health. I waive my right of informed consent to such treatment.

I also give my permission for my child to be transported by ambulance or aid car to an emergency center for treatment.

I certify, under penalty of perjury under the laws of the State of Washington, that this information is true and correct.
Parent Handbook Here
Parent/ Guardian #1 Signature*

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Date*

MonthDayYear
Date
Parent/ Guardian # 2 Signature

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Date

MonthDayYear
Date

Other Forms

Statement of Understanding
I, Parent's Name* , have read and understand all policies and procedures outlined in the parent handbook, including the payment policy, parent requirements, arrival and departure procedures, health policy, and reporting child abuse, pesticides and disaster plan. I agree to abide by these stated policies and procedures. I understand that if I have any questions regarding policies, I should speak with the center director or managing staff.
Signature*

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Date*

MonthDayYear
Date

Additional Medical Policies
Starting August, 1 2020, all immunization records turned in to schools or childcare centers are required by state law to be medically verified. Immunization records must be turned into the school on or before the first day of attendance. This means immunization records turned in to the school must be from a health care provider, or you must attach paperwork from a health care provider to your handwritten form that shows your child's records are accurate. Your child cannot attend school until you provide these records.

Here is an example of medically verified immunization records.

Please be sure to read the following and initial.
1. Prior to enrollment, I must provide the center with updated medical and immunization information for my child. This information is to be kept current and updated in acccordance with state childcare regulations.
2. I agree to provde information to the childcare center about my child's conditions, illnesses, allergies or other needs.
3. If my child becomes ill with a reportable contagious disease, I undestand that he/she will not be able to return until I bring in a physician's note stating that he/she is no longer contagious.
4. If my child becomes ill during his/her time at the childcare center, the staff will contact me to pick up my child. I will arange for pick up as soon as possible and no later than 2 hours after being contacted. If I cannot be reached, the staff will contact those listed in the Child Emergfency Contanct and Release form.
Initial here*

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Celebrated Holidays
Due to the various cultures in our center, we would like to get parent input for the upcoming calendar year, HEre is a list of the holidays we typically celebrate during working hours with the children.
- Valentines Day- share candy and goodies
- Easter- egg hunt
- Cinco de Mayo
- Mother's Day
- Father's Day
- Halloween- costumes are allowed
- Thanksgiving- we do a lunch feast with the children
- Christmas- decorated, and Santa comes to daycare
Are there other holidays that your family celebrates at home that you would like us to celebrate at our center with the children?*

NoYes
Explain*
Are there holidays you would like us to NOT celebrate with your child? Or holiday-specific items you are NOT OK with us having?

NoYes
Explain*
If there is a holiday you don't celebrate at home, is it ok for us to celebrate with the children here at daycare?*

NoYes
Explain*
Thank you for your input on this matter. We would like to celebrate and honor cultures, backgrounds and holidays that are important to all our families.
Parent's Name*
Signature*

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Date*

MonthDayYear
Date

Early Achievers Parent/Guardian Consent Form
Dear Families,

As you know, My Little Planet Learning Center, is participating in Early Achievers and we are preparing to demonstrate our commitment to providing quality care and education through an on-site evaluation. We need your help to make this effort a success! Please read below for more information on how you can help us continue to provide high-quality care that helps children learn and grow.

On-site Evaluation

Childcare and early learning programs that participate in Early Achievers receive on-site evaluation visits from the University of Washington (UW). The purpose of the evaluation visit is to gather information about our program to inform our Early Achievers quality rating. An onsite observation of our learning environment during operating hours is part of our evaluation.

The evaluation includes collecting information that will be used to validate our quality and help us, My Little Planet Learning Center, develop goals to continue improving the quality of care we provide for your child, such as:
- Observing interactions between providers and children.
- Observing the materials, activities and experiences available to support children in the learning environment.
- Observing children engaging with the learning environment to understand how it stimulates their learning.
- Interviewing providers about how they support young children's growth and development.
- Interviewing interesteed families to learn about how we partner with families to support heir childs learning and development.
- reviewing program files and documentation to learn how program policies and procedures support quality childcare practice.
- Reviewing child files to see how our program supports each child's learning and development.
Please Note:

Your child's care and education will not be interrupted during this process.
- No information about your child will ever be released to the public.
- No identifiable information about individual children will be collected.
- information about our participation will be posted on the Department of Early Learning and Childcare Aware of Washington website (del.wa.gov and wa.childcareaware.org)
Consent for on-site evaluation

Please let us know if your child's files can be included during the evaluation visit.
I allow my child's files to be reviewed as part of the Early Achievers evaluation as outlined above.I would like my child's files to be excluded during this process.
Optional

The UW data collection team would like to hear what you think about how we work with children and families. IF you are interested in participating in an interview with the UW team, please indicate below:
Phone Number
Please enter a valid phone number.
Best time to reach my by phone:
Please contact me by email so I can access a link to an online parent survey.
Email
example@example.com
Signature*

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Date*

MonthDayYear
Date

Supplies and Information

Please read the following.

Emergency Comfort Kit List
Emergency Comfort Kit List

Thinking about things such as natrual disasters or crisis can be frigtening but it helps everyone feel ore secure knowing that we are well prepared and equipped to care for and protect your child if you are unable to get to him or her right away.

In order ot make that happen, My Little Planet Learning center requires each family to provide their child with a comfort kit to be with our center's disaster supplies.

The purpose of a comfort kit is to keep your child comfortable and reassured in the event of an unexpected occurence such as an earthquake, storm, power outagem crisis or another emergency.

The comfort kit should include:
- Photo of Family
- A Flash Light w/ Battery
- Emergency Mylar Blanket
- Small Stuffed Animal
- Snacks
- Bottled Water
* These items must be stored in a Ziploc gallon- sized bag and labeled with the child's name.

School Supply List
School Supply List

Please provide the following :
- 2 extra complete changes of clothes (stored in a gallon Ziploc bag)
- Coat (appropriate seasonal outdoor wear)
- Extra pair of shoes
- 2 Boxes of facial tissues

Communication with My Little Planet
Communication with My Little Planet

Email: mylittleplanetdcc@gmail.com

Phone: 509-582-7301

Address: 316 S. Auburn St. Kennewick, WA 99336

Procare Parents Connect: myprocare.com
Should be Empty:

My Little Planet Learning Center Enrollment Form

Child Registration Form

Family Information

Child Emergency Contact & Release Information

Childcare Agreement Form

Medical Consent & Provider Information Form

Health & Medical History Form

Disease History

Allergies

Miscellaneous Screenings and Tests

Other Forms

Other Forms (continued)

Permission for Photograph/Media

Supplies and Information