ENROLLMENT FORM

Rising Stride Location*

Child's Name*

First NameMiddle NameLast Name

Child's Date of Birth*

Child's Start Date*

Payment Type (more than one may apply)

Full-Day TuitionFull-Day ELRCPreK Counts (FREE - NO FEES)Extended Care Tuition (for PreK Counts funded children)Extended Care ELRC Part-Time (for PreK Counts funded children)

Days of Week

Days of Week (Before Care)

Days of Week (After Care)

Drop-Off Time

7 :00 to 9:00 am7:00 to 8:30 am (on days your child IS enrolled in Before Care)Promptly at 8:30 am (for PreK Counts students who ARE NOT enrolled in Before Care)

Pick-Up Time

2:00 to 6:00 pm (late fee of $1 per minute applies after 6:00 pm)Promptly at 2:00 pm (for PreK Counts students who are NOT enrolled in After Care)

Meals:

Infant: Parents required to pack all meals (formula or breastmilk, baby food, and beverages)13 months and up: Rising Stride provides breakfast, afternoon snack, and beverages; Parents required to pack lunch.Assigned to PreK Counts classroom: Rising Stride provides breakfast, lunch, afternoon snack, and beverages (due to grant requirements).

ELRC Region

Caseworker Name

Record #

Date of ELRC Call or Email

Subsidy Start Date

Days of Week (Subsidy Schedule)

Weekly Copay Amount (due each Monday for that week)

Promotion Type

One-Time Registration Fee ($0 for ELRC, ITCS, and PKC only families)

Security Deposit ($0 for ELRC, ITCS, and PKC only families)

Total Received, Check/Mo #, Date Received

Name of Rising Stride Manager agreeing to the above:

By entering full name into the field above, manager agrees to the use of online signatures.

Child's Preferred Name/Nickname

Child's Street Address*

Child's Apt/Suite

Child's City*

Child's State*

Child's Zip Code*

Child's Gender*

Parent/Guardian #1 - Full Name*

First NameMiddle NameLast Name

Parent/Guardian #1 - Relation to Child*

Parent/Guardian #1 - Street Address*

Parent/Guardian #1 - Apt/Suite

Parent/Guardian #1 - City*

Parent/Guardian #1 - State*

Parent/Guardian #1 - Zip Code*

Parent/Guardian #1 - Email Address*

example@example.com

Parent/Guardian #1 - Cell Phone*

Parent/Guardian #1 - Home Phone

Parent/Guardian #1 - Work Phone

Please enter a valid phone number.

Parent/Guardian #1 - Employer Name

Parent/Guardian #1 - Employer Full Address

Parent/Guardian #1 - Employer Phone

Parent/Guardian #2 - Full Name

First NameMiddle NameLast Name

Parent/Guardian #2 - Relation to Child

Is Parent/Guardian #2 address the same as Parent/Guardian #1 address?

Parent/Guardian #2 - Street Address

Parent/Guardian #2 - Apt/Suite

Parent/Guardian #2 - City

Parent/Guardian #2 - State

Parent/Guardian #2 - Zip Code

Parent/Guardian #2 - Email Address

example@example.com

Parent/Guardian #2 - Cell Phone

Parent/Guardian #2 - Home Phone

Parent/Guardian #2 - Work Phone

Please enter a valid phone number.

Parent/Guardian #2 - Employer Name

Parent/Guardian #2 - Employer Full Address

Parent/Guardian #2 - Employer Phone

Which Parent/Guardian is responsible for this child's account?

The following individuals are authorized to aid my child in emergency situations when parents or legal guardians cannot be contacted.

Note: The State of Pennsylvania requires complete addresses and telephone numbers for all emergency contacts.

Emergency Contact #1 - First and Last Name*

Emergency Contact #1 - Relation to Child*

Emergency Contact #1 - Full Address*

Emergency Contact #1 - Phone 1*

Emergency Contact #1 - Phone 2

Emergency Contact #2 - First and Last Name

Emergency Contact #2 - Relation to Child

Emergency Contact #2 - Full Address

Emergency Contact #2 - Phone 1

Emergency Contact #2- Phone 2

Emergency Contact #3 - First and Last Name

Emergency Contact #3 - Relation to Child

Emergency Contact #3 - Full Address

Emergency Contact #3 - Phone 1

Emergency Contact #3 - Phone 2

Emergency Contact #4 - First and Last Name

Emergency Contact #4 - Relation to Child

Emergency Contact #4 - Full Address

Emergency Contact #4 - Phone 1

Emergency Contact #4 - Phone 2

If I am unable to pick up my child, I authorize Rising Stride to release my child to the persons listed below. I understand that no further written authorization from me is required. I understand that I must update and submit this form if any changes.

Please note: For the safety of your child, please inform all authorized pick-up persons listed herein that we will ask for government issued photo ID when they arrive to pick up your child. If they do not have a government issued photo ID with them, we WILL NOT release your child to them under any circumstance.

The State of Pennsylvania requires complete addresses and phone numbers for all authorized pick-up individuals.

Release Contact #1 - First and Last Name

Release Contact #1 - Relation to Child

Release Contact #1 - Full Address

Release Contact #1 - Phone 1

Release Contact #1 - Phone 2

Release Contact 2 - First and Last Name

Release Contact #2 - Relation to Child

Release Contact #2 - Full Address

Release Contact #2 - Phone 1

Release Contact #2 - Phone 2

Release Contact #3 - First and Last Name

Release Contact #3 - Relation to Child

Release Contact #3 - Full Address

Release Contact #3 - Phone 1

Release Contact #3 - Phone 2

Release Contact #4 - First and Last Name

Release Contact #4 - Relation to Child

Release Contact #4 - Full Address

Release Contact #4 - Phone 1

Release Contact #4 - Phone 2

Physician Name*

Physician Full Address*

Physician Phone*

Insurance Carrier*

Name of Policy Holder*

Policy Number*

Group Number

Allergies

Current Medications

Medical Conditions

Disabilities

Medical or Dietary Information Needed in an Emergency

Special Needs

Additional Information

Do you authorize Rising Stride to obtain emergency transportation to and/or emergency medical care for your child at the nearest hospital's emergency room, or at the emergency room the EMS/Ambulance Service is required to transport patients to at the time of emergency.*

yes

Do you authorize Rising Stride to administer minor first aid procedures as needed for your child?*

yes

Do you authorize our use of photographs and videos of your child on our website, social media page, newsletter, slideshows, and promotional materials? No child's name will be published alongside the images.*

yesno

Do you authorize application of non-prescription over-the-counter (OTC) sunscreen to your child?*

yesno

Do you authorize your child's participation in walking excursions on premises immediately surrounding the facility?*

yesno

Rising Stride uses their family smartphone app to keep parents updated and to communicate in the event of an emergency. Do you agree to download and maintain access to the family smartphone app?*

yesno

My signature confirms my agreement with the following statements:*

I confirm that I have been given the opportunity to read the Family Handbook, ask questions about it, understand the policies contained therein, and agree to abide by the policies. Rising Stride reserves the right to alter, amend, or otherwise modify these guidelines, in its sole discretion, without prior notice. The Family Handbook is available inside the family app and on paper in the office at each location.I understand that I will be entering into a Contract for Early Education and Child Care Services with Rising Stride. Rising Stride agrees to provide services for my child in accordance with the mission, philosophy and policies outlined in the Family Handbook. I know how to login to my family portal and see my regular amount due on Monday of each in accordance with the Payment Policies set forth in the Family Handbook. I am also able to view my transaction history and the contact information for the Account Manager with any questions about my account.I understand that any requests for changes to the enrollment schedule listed herein must be made in writing and submitted to the Director in accordance with the Family Handbook policies. Rising Stride reserves the right to deny any request for schedule change for any reason within its sole discretion.The Contract for Child Care Services may be cancelled by Rising Stride at any time with or without notice, in its sole discretion. The Contract for Child Care Services may be cancelled by the parents/guardians with two weeks written notice. Written notice of cancellation must be submitted to the Director.I confirm that I have had the opportunity to discuss the information contained herein with a representative of Rising Stride, that my questions have been answered fully and to my satisfaction and that I agree to abide by the conditions set forth herein as well as the policies contained herein by reference from the Family Handbook.I received complete written program information at the time of enrollment. ($3270.121, $3280.121, $3290.121) I I agree to update the emergency contacts and parental consent information whenever changes occur or every 6 months at a minimum. ($3270.124, $3280.124, $3290.124)

By entering my full name here, I agree to the use of Electronic Signatures.*

Parent/Guardian Full Name Here

Parent/Guardian Signature*

Signature Date*

ENROLLMENT FORM

THIS SECTION IS TO BE COMPLETED BY DIRECTOR

ELRC CONFIRMATION INFO

INITIAL PAYMENT RECEIVED

THIS SECTION IS TO BE COMPLETED BY PARENT/GUARDIAN

PARENT/GUARDIAN #1 INFORMATION

PARENT/GUARDIAN #2 INFORMATION

EMERGENCY CONTACTS

PERSONS TO WHOM CHILD MAY BE RELEASED

CHILD'S MEDICAL INFORMATION

AUTHORIZATIONS