Enrollment Application

Date of Enrollment*

Date

Child's Full Name*

First NameLast Name

Child's Date of Birth*

Date

Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Child's Gender*

MaleFemaleOther

Does your child dress their self?*

YesNo

Does your child undress their self?*

YesNo

Is your child, right or left handed?*

Right HandedLeft Handed

Is your child vegetarian?*

YesNo

Does your child have frequent colds?*

YesNo

Does your child vomit easily?*

YesNo

Does your child run high fevers easily?*

YesNo

Does your child have asthma?*

YesNo

Does your child experience hives?*

YesNo

Does your child experience hayfever?*

YesNo

Does your child been to the dentist?*

YesNo

Does your child been vision tested?*

YesNo

What time does your child eat breakfast, lunch and dinner?*

What time does your child go to bed? Awaken?*

Eating problems or any dietary restrictions, please explain:*

Child's favorite indoor play activities:*

Does you child have any fears? Explain:*

Does you child have any allergies? Explain:*

What is your method to behavior modification?*

How would you describe your child's personality?*

What illness has your child had at what age? ex: chicken pox, mumps, measels, diabetes, etc.*

Does your child experience the below, often?*

TonsilitisStomach AcheEar Ache

Parent/Guardian Full Name**

First NameLast Name

Parent/Guardian Full Name

First NameLast Name

Parent/Guardian Phone Number**

Please enter a valid phone number.

Parent/Guardian Phone Number

Please enter a valid phone number.

Parent/Guardian Email Address*

example@example.com

Parent/Guardian Email Address*

example@example.com

Home Address**

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Child Shirt Size **

Emergency Contact Name**

First NameLast Name

Emergency Contact Phone Number**

Please enter a valid phone number.

Emergency Contact

First NameLast Name

Emergency Contact Phone Number*

Please enter a valid phone number.

Is anyone else authorized to pick up your child?**

YesNo

If yes, please list names and contact information for authorized pick-up persons.*

Does your child have any allergies or medical conditions?**

YesNo

If yes, please provide details about allergies or medical conditions.*

Please share any additional information or special needs we should be aware of.*

Admission Agreement
1. Childcare between A.M./P .M. to A.M./P .M. for______________ ___ _days per week as prearranged, excluding days the center is closed. 2. The child shall be given breakfast if arriving before 8:00 A.M., lunch between 11:00 A.M.-12:00 P .M.(not provided by center),and a mid-afternoon snack for children who are at the center after 2:00 pm. 3. The child shall be given assistance with personal care as needed. 4. The child will be provided with an opportunity to nap between 12:30-2:30pm on a cot or crib provided by the center. 5. The child shall be placed in a group of peers based on age and/or special needs, as determined by the staff. 6. The child will be involved in a program of learning experiences and play, which are appropriate for the ages of the children enrolled in the center. A balance of active and quiet play is provided for, with individual and group activities, which are geared toward the emotional, social, physical, and individual growth of young children. 7. The center shall assume responsibility for the child after the parent signs in the child and has notified the teacher. The center shall retain responsibility until the child is signed out by the parent, guardian, or designated representative of the child’s parent or guardian. 8. The child shall be administered physician prescribed medication only upon the written daily request of the child’s parent or guardian. The center shall not administer a non-prescription medication unless it is accompanied by a written daily request from the child’s parent or guardian. The center shall have no responsibility of any kind whatsoever, neither for failure to provide requested prescription medication nor for adverse reaction, which may be caused by the administration of such prescription medication. 9. The center shall give appropriate first aid to an injured child. A parent or guardian shall be contacted if it is the judgment of the staff that immediate medical attention is necessary. If it is the further judgment of the staff that the injury is of an emergency nature, paramedics shall be called to the school and a parent or guardian shall be contacted. 10. An ill child shall be isolated and given appropriate care until called for by a parent, guardian, or a designated representative. 11. The center shall notify the child’s parent or guardian of a suspected exposure to a communicable disease. 12. The center shall make every effort to safeguard personal belongings brought by the child, but shall not be responsible for lost or broken items. 13. The Directors or any other staff members shall report to Children’s Protective Services of the Police Department, of any suspicion of child abuse, sexual or otherwise, neglect, or endangerment of which they may become aware. State law mandates this. PAYMENT PROVISION In accordance with the statement of fees in the parent handbook: 1. A non-refundable registration fee shall be paid upon enrollment. 2. Tuition Fees shall be paid on the first day of the week in which care will be given. A late fee of $5.00 per day shall be added for late payments. 3. Two weeks notice shall be given to the center before withdrawing from the program. If notice is not given, parent or guardian is responsible for two weeks tuition. 4. Each full time (4-5 days per week) enrollment in the program is given one week of vacation in which tuition will not be due for absence. The center shall be notified one week prior to vacation.OBLIGATION OF PARENT OR GUARDIAN1. A parent or guardian shall furnish requested medical information not more than 15 days after enrollment. 2. A parent, guardian, or designated representative of the child’s parent or guardian shall bring the child into the center upon arrival and sign in on the appropriate register. 3. A parent, guardian or designated representative of the child’s parent or guardian shall sign the child out on the appropriate register and notify the teacher before taking the child from the premises. 4. The parent or guardian shall notify the center when someone other than those names on the emergency information card will be picking up the child. 5. The parent or guardian with a child attending during nap time (staying at the center after 12:30pm) are required to bring 1 crib sheet and a small blanket. 6. The parent or guardian shall see that the child is dressed appropriately when brought to the center. 7. The parent or guardian shall notify the center of the child’s possible exposure to a communicable disease. 8. The parent or guardian shall notify the center when the child is to be absent. 9. The parent or guardian shall abide by the parking rules of the center. 10. The parent or guardian shall notify the center when signing in if there is a change in the child’s daily schedule. 11. The parent or guardian shall refrain from reprimanding children while on the premises. 12. The parent or guardian shall come to the center for conferences when asked to do so by a member of the staff. TERMINATION OF AGREEMENT This agreement can be terminated in any of the following circumstances: 1. Serious illness of the child, preventing attendance. 2. The parent or guardian of the child allows their account to become delinquent. 3. Failure of the parent or guardian to honor the obligations listed in this agreement or in any rules, regulations or manuals provided by the center. 4. The center in its sole discretion determines that it is unable to meet the needs of your child. 5. The center in its sole discretion determines that it is not in the best interest of the center or the other children enrolled at the center, to have the child in attendance. 6. Failure of the child’s parent or guardian to cooperate with the center, which the center determines in its sole discretion, is serious enough to warrant termination.

Permission to participate in center activities + medical authorization
I hereby grant permission for my child to use all of the play equipment and participate in all of the activities of the center, and to leave the center premises under the supervision of a staff member for neighborhood walks or for field trips in an authorized vehicle. This includes using areas included in the property surrounding the center.I hereby grant permission for the Director or Acting Director to take whatever steps may be necessary to obtain emergency medical care. These steps may include, but are not limited to, the following: 1. Attempt to contact a parent or guardian, the child’s physician, or the persons listed on the emergency information form. 2. If we cannot contact you or your child’s physician, we will do one or both of the following: a. call another physician or paramedics have a child taken to an emergency hospital in the company of a staff member. 3. Any expenses incurred under 2, above, will be born by the child’s family. 4. The center will not be responsible for anything that may happen as a result of false information given at the time of enrollment. 5. The center WILL NOT assume responsibility for a child who has not been signed in upon arrival for the day. MEDICAL AUTHORIZATION: The undersigned, who are the parent(s) or guardian(s) having legal custody of the above named minor, hereby authorize the above named child care center, into whose care the above named minor has been has been entrusted, to consent to any x-ray examination, anesthetic, medical or surgical diagnosis or treatment, and hospital care to be rendered to said minor under the general or special supervisor and upon the advice of a physician and surgeon licensed under the provision of the Medical Practice Act, or to consent to an x-ray examination, aesthetic, dental or surgical diagnosis or treatment and hospital care to be rendered to said minor by a dentist licensed under the provisions of the Dental Practice Act.The undersigned further authorize the above named childcare center to have the above named minor released into custody of its representative, should hospital care no longer be required. This form is to be used ONLY in an extreme EMERGENCY , when said parent(s) or guardian(s) who cannot be contacted or are unavailable.

I acknowledge that the information provided is accurate and I agree to the daycare's enrollment policies.

I agree

The center shall provide the following basic services for First Name Last Name , Birth Date . Whose parent guardian is, First Name Last Name and relationship to child Relationship

For services listed in this agreement, and in accordance with the terms of this agreement, I agree to pay Borrowed Babies Daycare LLC, a center of nurturing and child development, a weekly sum of$ which is agreed on at the time of enrollment. I agree to cooperate with the general policies of the center, to perform of obligations parents set forth in the agreement, and to abide by the rules, regulations, and manuals provided by the center. My signature below indicates that I have read the terms of this agreement.

Parent/Guardian Signature*

Parent/Guardian Signature

Owner/Director Signature*

Custody/Visitation Arrangements:*

Brother/Sister of Child - Name and Age:*

Other Members of Household - Relation and Age:*

Notes about your child’s habits, likes, dislikes, etc.*

Child's Physician, Phone Number and Emergency Hospital Preference*

Any physical or mental delays and/or special needs? If yes, explain, Phone Number and Emergency Hospital Preference:*