Enrollment Packet

Enrollment Packet
Student Information
Name *

First Name Last Name
Parent/Guardian Name #1 *

First Name Last Name
Parent/Guardian Name #2

First Name Last Name
Date of Birth *

Month Day Year
Date
Gender *
Race/Ethnicity (optional)
Physical Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Is your mailing address the same as your physical address? *

Yes No
Mailing Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Home Phone *

Area Code Phone Number
Cell Phone

Area Code Phone Number
Email *
example@example.com
Special Needs (allergies, diet, medications, etc.)
How did you hear about us?

Permissions
Medical Transportation

I hereby give permission for New Beginnings Learning Center staff to obtain medical care for my child in the case of an emergency. If a medical emergency arises, program staff will take all steps necessary to ensure the safety of the student and will call if necessary a public emergency vehicle for transport to an emergency facility. I understand that I will be responsible for any transportation charges and medical expenses incurred. I agree that if a health condition exists now or in the future which would impact the participation of the student, I will notify the New Beginnings Staff.
(sign using your mouse or finger) *

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Media Release

I hereby give permission for New Beginnings Learning Center to use photographs and/or video that may include my student for use in any and all media distribution, including but not limited to brochures, newspaper articles, print advertisments, internet, newsletters, social media and email. New Beginnings will only use media for illustration, promotion and evaluation of the pogram.
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Child Care Animal Consent Form

In accordance with 922 KAR 2:120 Section 13, we are required to obtain parental or guardian consent to have non-native-to-Kentucky animals such as goldfish in the classroom.

Child Care regulatory policy will allow the following enclosed or caged classroom animals with parental consent: fish, hamsters, gerbils, guinea pigs, hermit crabs, turtles, birds, non-poisonous amphibians, bearded dragons, rabbits, chinchillas as well as caterpillars and butterflies.

Center's Name: New Beginnings Learning Center

Center's Address: 151 Miss Edna Lane, Hazard, KY 41701

Child's name: {name}

DOB: {dateOf}

I, {parentguardianName}, give my permission for my child, {name}, to be in the presence of the animals listed below.

Animals:

1. Goldfish and Beta Fish

2. Turtle

3. Frog
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Contract
Which class are you enrolling your child in? *

Nursery (6 weeks-1 year) 1-Year-Old Class 2-Year-Old Class 3-Year-Old Class 4-Year-Old Class After School Care
Are you interested in Full Time or Part Time care? *

Full Time Care (5 days/week) Part Time Care (3 days/week) Before/After School Care
Tuition
I {parentguardianName} agree to pay the rate of {tuition} for {name} for child care services while he/she is enrolled in the New Beginnings Learning Center. I further understand that if any time my payment is not made bi-weekly; my services will be suspended until account is brought current.
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Child's Record

Page 1
Date of Birth

Month Day Year
Date
Date of Enrollment *

Month Day Year
Date
Name

First Name Last Name
Parent/Guardian Email
example@example.com
Parent/Guardian's Name (Last, First, Middle)
Home Phone Number

Area Code Phone Number
Cell Phone Number

Area Code Phone Number
Name Parent/Guardian #1
Place of Employment ~ Parent/Guardian #1
Work Phone Number ~ Parent/Guardian #1

Area Code Phone Number
Name Parent/Guardian #2
Place of Employment ~ Parent/Guardian #2
Work Phone Number ~ Parent/Guardian #2

Area Code Phone Number
Other Authorized Escort(s)/Phone Number(s)

Child's Record

Page 2 ~ Medical History
Name of Pediatrician or Family Practitioner
Name of Facility (UK, Hazard Clinic, etc.)
Office Phone Number

Area Code Phone Number
Name of Hospital of Choice
Hospital Phone Number

Area Code Phone Number
Diseases

Please write in the dates your child was ill or leave blank if s/he has not had the disease in question.
Whooping Cough:

Month Day Year
Date
Chicken Pox:

Month Day Year
Date
Mumps:

Month Day Year
Date
Measles:

Month Day Year
Date
Scarlet Fever:

Month Day Year
Date
Other:
Allergies:
I hereby authorize HPCCM to obtain emergency medical care for my child an to transport my child during an emergency.
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Date

Month Day Year
Date
Other Notes
Should be Empty:

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Enrollment Packet

Student Information

Permissions

Contract

Child's Record

Child's Record