Unlatched Success Learning Center Enrollment Application K83-0056743 CONTRACT# 29728

Unlatched Success Learning Center Application

License# K83-0056743 Contract# 29728
Child Information
Child's name*

First NameLast Name
MaleFemaleN/A
Date of birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian*

First NameLast Name
Phone number*
Please enter a valid phone number.
Place of employment*
Phone number*
Please enter a valid phone number.
Email*
Parent/Guardian Email - example@example.com
Emergency Contact

List individuals to notify, in case of emergency, when the parent or guardian cannot be reached. List in order of prference:
Emergency Contact #1*
Full name and phone number
Emergency Contact #2
Full name and phone number
Emergency Contact #3
Full name and phone number
Emergency Contact #4
Full name and phone number
Emergency Contact #5
Full name and phone number

Transportation
I do not give permission to transport my child.I give permission for my child to be transported by this program under the following circumstances:
When an emergency occurs and I cannot be reachedField tripsTo and from homeOther
Drop-off Time
Pick-up Time
Specific plan for transfer and supervision:
Pick Up Permission

Individuals who have permission to pick up my child:
Contact #1*
Full name and phone number
Contact #2
Full name and phone number
Contact #3
Full name and phone number
I ujnderstand this form is supplied by the Department of Human Services (DHS) for the conveince of the child care program and me to assist with care of my child. Supplying this form in no way imposes any responsibility or obligation upon DHS.

Program policies are provided to parents upon enrollment and when revisions are made.Selecting Quality Child Care - A Parent Guide, DHS publication 87-91, Licensing Requirements for Child Care Programs, DHS publication 14-05, and the program compliance file are all made accessible to parents in a prominent location.
Signature*

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Date*

MonthDayYear
Date
Child Care Program Use

Date child entered program: Date child withdrawn:

Photo Release Form
I, First Name Last Name , the parent or legal guardian of First Name Last Name grant Unlatched Success Learning Center permission to use photos of my child, and agree to the following:
I understand that my child, whose name is listed above, may be photographed, or their images recorded for print or electronic use in promoting the Center's sertvices. I understand that it is my responsibility to update this form in the event that I no longer wish to authorize the above uses. I agree that this form will remain in effect during the term of my child's participation in this release.
Parent/Guardian Signature*

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Parent/Guardian Name*

First NameLast Name
Child's Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Date*

MonthDayYear
Date

Compliance File Notification:

Child Care Programs and Family Child Care Homes
Unlatched Success Learning Center

K830056743

3720 S Sunnylane Rd Del City, OK 73115

405.604.0909

Owner: Brodrick Mannings

Child Information

Please list the name(s) and birth date(s) for any child(ren) you are enrolling in this program (if you have more than three children bneing enrolled please let administration know):
Name (1st Child)*

First NameLast Name
Birth Date (1st Child)*

MonthDayYear
Name (2nd Child)

First NameLast Name
Birth Date (2nd Child)

MonthDayYear
Name (3rd Child)

First NameLast Name
Birth Date (3rd Child)

MonthDayYear
Agreement and Signature
this program is required to maintain a copy of the compliance file on-site and the information contained in the file is available for inspection.of the Compliance File location and its contents.this form is to be completed:upon child enrollment: andevery 12 months thereafter.a copy of the program specific Notice to Parents is to be provided to parent(s) or legal guardian(s) upon enrollment.
DHS Publication No. 14-01, Notice to Parents for Child Care ProgramForm 07LC084E, Notice to Parents for Family Child Care Home
Signature*

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Date*

MonthDayYear
Date

Compliance File Notification: Child Care Programs and Family Child Care Homes

This document does not meet posting requirements per OAC 340:110-3-275 through 340:110-3-311, and DHS Pub 14-15 Licensing Requirements for Child Care Programs, and is a parent provided document only, information contained in DHS Pub 14-01 by calling 1-877-283-4113, or by faxing (405)962-1741.

NOTICE TO PARENTS

Please review the following records on a regular basis at child care centers, day-camps, drop-in programs, out-of-school time programs, part-day programs, and programs for sick children.

Posted: The program is required to post:
- This Notice to Parents; and
- Child Welfare Investigate Summary, with confirmed and substantiated frindings for 120 calendar days from the date the investigation is completed as indicated on the form.
Compliance file: The program is required to make accessible in a prominent location the following documents, maintained together, with the most recent on top and all child-identifying information removed. The compliance file includes items within the last 120 calendar days, at a minimum, from the date on the document or the investigation completion date on the form, unless requirements state otherwise.

The compliance file only contains; compliance monitoring from Licensing, Stars and tribal agencies, such as: monitoring visit forms; including the most recent visit; case status information; such as forms and correspondence regarding: issuance of permits and licenses; non-compliances and Stars violations; notices to comply; complaint findings; office conferences with Licensing, Stars and tribal agencies; Stars alternative settlements and reducations; consent agreements, denials of a request for license, and revocations of a license; child welfare investigate summary, regardless of findings; however, confirmed or substantiated findings are maintained in the file for 12 months; granted criminal history restriction waiver notifications are maintained in the file for as long as the individual is employed or is living in the facility; and other documents indicating placement in the compliance file.

Online

Child care locator and case summary: Access at the below Web Address.

Licensing requirements for child care programs: Access at the below Web address or contact the local DHS office below for a mailed copy.

At the DHS local office

Public licensing file: Contact the local office below to schedule an appointment.

Case summary: Cotact the local office below for a faxed or mailed copy.

If you believe licensing requirements are not being met or you have questions, please contact a child care licensing specialist from GDHS Child Care Services at:

DHS local office

Child Care Services

Address: 631 E. Robinson Norman, OK Phone: 405-5738300

http:www.okdhs.org/services/cc/Pages/ChildCareMain.aspx
Signature*

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Authorization to Dispense External Preparations
Parental Authorization. Except for first aid, personal shall not dispense prescription medications to a child without specific written authorization from the child's physician or parent. Such authorization will include, when applicable, date; full name of the child; name of the medication; prescription number, if any; dosage: the dates to be given; the time of day to be dispensed; and signature of parent. I give Unlatched Success Learning Center permission to apply one or more of the following topical ointments/preparations to my child in accordance with the directions on the label of the container.*

Baby WipesBand-aideNeosporin or similar ointmentBactine or similar first aid spraySunscreenInsect RepellentNon-Prescription ointment (such as A&D, Destin, Vaseline)Baby PowderOther
Signature*

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Date*

MonthDayYear
Date

Insurance Notification:

Child Care Programs and Family Child Care Homes
Unlatched Success Learning Center

K830056743

3720 S Sunnylane Rd Del City, OK 73115

405.604.0909

Owner: Brodrick Mannings

Child Information

Please list the name(s) and birth date(s) for any child(ren) you are enrolling in this program (if you have more than three children being enrolled please let administration know):
Agreement and Signature
does not maintain general liability insurance coverage, as defined by Section 707 of Title 36 of the Oklahoma Statues, of at least two-hundred-thousand dollars ($200,00) for each occurence of negligence. This insurance would cover injury to a child due to negligence that occurs while the child is in the care of the child care program.reports self-insurance in accordance with state law.is required to post Form 07LC093E, Insurance Exception Notification in a conspicuous location.Select for a copy of Form 07LC093E, Insurance Exception Notification which is to be provided to parents upon enrollment or when information changes.
upon child enrollment; andevery 12 months thereafter
Name (Parent/Guardian)*

First NameLast Name
Signature*

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Date*

MonthDayYear
Date

Reasons for Explusion & Absences
Reasons for Explusion
- Failure of child to adjust after a reasonable amount of time
- Uncontrollable tantrums/angry outbursts
- Ongoing physical or verbal abuse to staff or other children
- Excessive biting
- Willful damage to property
- Parents exhibit verbal abuse in front of enrolled children
- Habitual tardiness in picking up your child/children after (10) hours per day or after the center has closed at 6:00 p.m.
Prior to explusion, a parent will be called and notice will be given indicating what the problem is.

Every effort will be made by both the center and the parent to correct the problem.

If behavior does not improve after one or two weeks of non-clinical observations, the parent will be asked to consider withdrawing the child/children from the program.

The parent will be given a minimum of one week's notice to find another child care provider.

If payment has been made for the period, the amount of refund will be prorated.

Absences

Childcare fees are based on enrollment (a reserved space), not on attendance. To maintain a reserved space, fees must be paid during the absence of a child due to illness, holidays, vacation, or for any other reason.
Signature*

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Should be Empty:

Unlatched Success Learning Center Application

Child Information

Health Record

Transportation

Photo Release Form

Compliance File Notification:

Authorization to Dispense External Preparations

Insurance Notification:

Reasons for Explusion & Absences