New Family Registration Form

Welcome to A Little Village Montessori Daycare / Preschool

in Santa Clarita

Child Registration Process

One Child Per Registration

TO ALL OF OUR PROSPECTIVE CLIENTS: We are delighted to have you enroll your child with A Little Village Daycare. We want to let you know up front that, due to state and federal childcare regulations and form requirements, this enrollment form is a bit long. Please hang in there with us as our thoroughness helps us to take the best all around care of your child.

PLEASE ALSO NOTE: Please be prepared to upload a copy of your child's immunization records during this process.

Thank you!

CONSENT FOR EMERGENCY MEDICAL TREATMENT - CHILD CARE CENTERS OR FAMILY CHILD CARE HOMES State of California - Department of Health & Human Services Agency/California Department of Social Services - Form LIC 627 (9/08) (CONFIDENTIAL)
Child's Full Name:*

First NameLast Name
As the parent or authorized representative, I hereby give consent to A Little Village DayCare, INC to obtain all emergency medical or dental care prescribed by a duly licensed physician (M.D.), osteopath (D.O.) or dentist (D.D.S.).

This care may be given under whatever conditions are necessary to preserve the life, limb or well being of the child named above.
Child has the following medication allergies:*
Full Name of Parent or Authorized Representative:*

First NameLast Name
Signature*

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Full Name of Signer:*

First NameLast Name
Date Signed:*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone: *
Please enter a valid phone number.
Home Phone:
Please enter a valid phone number.

PARENT CONSENT FOR ADMINISTRATION OF MEDICATIONS [BY ALittleVillageDaycare] AND MEDICATION CHART State of California -[ Health and Human Services/California Department of Social Services, LIC 9221 (8/08)

A Little Village DayCare, INC Family Child Care Licensing #197700976
Do you need A little Village Daycare, and its employees, to administer any prescription or nonprescription medications to your child at this time?*

YesNoOther
Signature*

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Name of Signer:*

First NameLast Name
Date Signed:*

MonthDayYear
Date
PLEASE NOTE THE FOLLOWING REGARDING ADMINISTRATION OF MEDICATION:

This form applies to the administration of prescription AND non-prescription medications.

Non-prescription medications include, but are not limited to, diaper cream, sunscreen and other topical non-prescription creams or ointments.

A Little Village Daycare is required to have one Medication Administration form for each prescription and non-prescription medication. We know that this is inconvenient, but our staff members are required to keep daily logs of the administration of any prescription or non-prescirption medication on each form.

Additional forms can be obtained by contacting A Little Village DayCare.

All medications must be in sealed containers with the pharmacy label on them that clearly contains the child's name, the name of the medication, dosages and times of day to be administered, and the expiration date. A Little Village Daycare staff members cannot administer medications without the pharmacy label or product instructions. A Little Village Daycare also cannot administer expried medications.  No exceptions.

All medications must be handed directly to a staff member each day at the time of drop off.  A Little Village Daycare staff members cannot be responsible for administering medications put inside diaper bags or any other like enclosed containers.

Thank you.
Signature*

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Name of signer:*

First NameLast Name
Date Signed:*

MonthDayYear
Date
IMMUNIZATION RECORDS
Please upload your child's most recent immunization records here:*

Cancelof

IDENTIFICATION AND EMERGENCY INFORMATION - CHILD CARE CENTERS/FAMILY CHILD CARE HOMES State of Califonria - Department of Health & Human Services Agency/Department of Social Services Community Care Licensing Division - Form LIC 700 (8.08) (CONFIDENTIAL)

To Be Completed by Parent or Authorized Reresentative
Child's Full Name*

First NameLast Name
Child's Gender:*

MaleFemalePrefer Not to Say
Child's Birth Date*

MonthDayYear
Date
FATHER'S/GUARDIAN'S/FATHER'S DOMESTIC PARTNER'S FULL NAME:*

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

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
MOTHER'S/GUARDIAN'S/MOTHER'S DOMESTIC PARTNER'S FULL NAME:*

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

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Person Responsible for Child [Name]:*

First NameLast Name
Additional Persons Who May Be Called In An Emergency

Emergency Contact
Full Name*

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

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Relationship to Child:*
Physician or Dentist to Be Called In An Emergency
PHYSICIAN:*
Phone Number*
Please enter a valid phone number.
DENTIST:*
Phone Number*
Please enter a valid phone number.
If Physician cannot be reached, what action should be taken?*

Call Emergency HospitalOther
Full Name of Signer*

First NameLast Name
Signature*

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Date Signed:*

MonthDayYear
Date

MARKETING/ADVERTISING

From time-to-time, A Little Village Daycare, and its employees or professional vendors, take photos and/or videos of the daily activities at the Childcare for promotional purposes. A Little Village Daycare uses these photos and/or videos at its Open Houses, on its website and on the social media platforms used by A Little Village Daycare. Accordingly, your child may by included in these photos and/or videos. We understand that not all parents wish to have their child included in these promotional materials.
Please indicate your election below:*

I consent to have my child's inclusion in photos and/or videos for purposes of promotion of A Little Village DaycareI decline to have my child's inclusion in photos and/or videos for purposes of promotion of A Little Village Daycare
Full Name of Signer:*

First NameLast Name
Signature*

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Date Signed:*

MonthDayYear
Date

PRICING

In addition to the monthly tuition, A Little Village Daycare has the following pricing at the time of this enrollment:
$275.00 one-time registration fee for Cotracts

$275.00 one-time registinos fee for FlexCare

$3.00 per minute for early drop off and late pickup before and after the designated times.

$35.00 late payment fee

$35.00 returned payment fee

$55.00 wait list fee (booked online)

3% processing fee for all credit card charges

There may be an additional cost for certain special events, field trips or other outings. A Little Village Daycare will notify you 2 weeks in advance if such an outing is being offered. Please note that the additional cost must be received by A Little Village Daycare no later than five days prior to the event or your child will be removed from the attendance roster.

A Little Village Daycare would love to host your child's birthday party! Please contact the Director to get pricing and make reservations.

I understand and acknowledge A Little Village Daycare's pricing as outllined above.
Termination

This contract may be terminated by either party at any time by giving the other party 30 days prior written notice. Termination without 30 days notice will be billed full amount of monthly tuition.
Full Name of Signer*

First NameLast Name
Signature*

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Date Signed:*

MonthDayYear
Date
Which program type have you selected:
Program Type*

Full TimePart TimeFlex Care
Full Time (Pick Up-Drop Off Time)

Hour Minutes

AM/PM Option

Until
until
Hour Minutes

AM/PM Option
Part Time (Pick Up-Drop Off Time)

Hour Minutes

AM/PM Option

Until
until
Hour Minutes

AM/PM Option
Part Time 2-3 Days (Pick Up-Drop Off Time)

Hour Minutes

AM/PM Option

Until
until
Hour Minutes

AM/PM Option

Part-Time 3 days per week requires fixed day schedule. Please select the date.

	Monday	Tuesday	Wednesday	Thursday	Friday
answer

TERMS AND CONDITIONS - FLEXCARE CLIENTS

Fee
- I am enrolling my child in the A Little Village Daycare child care program selected above.

- I understand that I will pay a one-time, non-refundable registration fee of $275.00.

- I agree that I am responsible for paying the fees and costs on the date of each visit and that A Little Village Daycare will make an ACH withdrawal from my account or make a charge to my credit card, whichever I have on file with A Little Village Daycare.

- If my payment is returned for any reason, I understand that a returned payment fee of $35.00 will be assessed and my child will be barred from further attendance at A Little Village Daycare until payment is received in full.

- If my child is dropped off before or picked up after the designated start and end times, I understand that a fee of $3.00 per minute will be assessed for the additional care time.

- I understand that in the event of any assessment described above, A Little Village Daycare will automatically make an ACH withdrawal or charge my credit card on the same day as the assessement is incurred.

- I understand that in the event that a meal or snack(s) is/are provided to my child, A Little Village Daycare will automatically make an ACH withdrawal or charge my credit card on the same day as the cost is incurred.

- I understand that no credit will be extended by A Little Village Daycare for vacations, holidays or in the event that the Daycare is shut down by government mandate due to COVID or any other contagious illness. Holidays include, but are not limited to, Labor Day, Memorial Day, Thanksgiving Day, the day after Thanksgiving, Christmas Eve, Christmas Day, New Year's Eve and New Year's Day.
Full Name of Signer*

First NameLast Name
Signature*

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Date Signed*

MonthDayYear
Date
TERMS AND CONDITIONS

ILLNESS AND MEDICATION
- I agree that any medications brought to A Little Village Daycare for A Little Village Daycare, and its employees, to administer to my child will be in sealed containers with the pharmacy label on them and clearly containing my child's name, the name of the medication, dosages and times to be administered and the expiration date. I further understand that A Little Village Daycare staff members will not administer expired medication to my child, without exception.

- I agree to hand all medications directly to a staff member each day at the time of drop off. I further agree that A Little Village Daycare staff members are not responsible for administering medications put inside diaper bags or any other like enclosed containers.

- In the event that my child is ill, I agree to notify A Little Village Daycare of my child's absence.

- I understand that if my child develops a fever over 100 degrees while at the Daycare, my child will be sent home.

- I agree that I will be readily available at all times to receive a call that my child is ill or in the event of any other emergency that may arise.

- I understand that I must provide A Little Village Daycare with a doctor's note releasing my child to return to daycare before my child returns to A Little Village.

- I undestand that in the event my child is sent home with a fever above 100 degrees, my child may not return to A Little Village Daycare until 24 fever-free hours have passed and a negative COVID test can be presented.

*I HAVE READ, UNDERSTOOD AND AGREE TO THESE TERMS AND CONDITIONS, AND TO ALL OF THE TERMS AND CONDITONS STATED THROUGHOUT THIS ENROLLMENT FORM.
Full Name of Signer*

First NameLast Name
Signature*

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Date Signed*

MonthDayYear
Date

GENERAL TERMS AND CONDITIONS
- A Little Village Daycare enrollment is open to any child regardless of race, color or religious affiliation provided that A Little Village Daycare can meet the needs of the child.

- A Little Village Daycare may not be suitable for children with auditory or sensory senstivities. If my child presents with any such symptons, I am responsible for having my child evaluated by a professional and for having a care plan put into place for continued care.

- I understand that A Little Village Daycare, and its employees, are required by law to report any sign of child abuse, or suspected child abuse, to the police and the Department of Human Services.

- I undestsand that, due to unforseen circumstances, it may be necessary for A Little Village Daycare to adjust my child's schedule. A Little Village Daycare will take every step to avoid such schedule changes.

- I agree to provide A Little Village Daycare with updated contact and emergency contact information and any other relevant new information in a timely manner.

- I understand that A Little Village Daycare is a NO NUT facility, including all tree nuts. Sun butter sandwiches need to be labeld with "sun butter" and brought to the attendtion of a staff member. No peanut butter is allowed.

- I agree to label ALL personal items brought to A Little Village Daycare for my child. Such items include, but are not limited to, bottles, bottle ice bag, food storage containters, diaper bag on the outside, blankets, sleep sack, swim gear and all clothing items.

- PLEASE NOTE that A Little Village Daycare will not release your child to anyone under the age of 18 years, including siblings. Further, A Little Village Daycare will not release your child to any person, including yourself or your spouse, if applicable, visibly under the influence of alchohol or any other substance.

- Authorized persons will be asked to present government-issued photo identification at the time of pickup for verification purposes.

*I HAVE READ, UNDERSTOOD AND AGREE TO THESE TERMS AND CONDITIONS, AND TO ALL OF THE TERMS AND CONDITONS STATED THROUGHOUT THIS ENROLLMENT FORM.
Full Name of Signer:*

First NameLast Name
Signature*

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Date Signed*

MonthDayYear
Date

PAYMENT AUTHORIZATION

A Little Village Daycare accepts payment by ACH or Debit Card/ Visa or Mastercard. ( No AMEX )PLEASE NOTE that there is a 3% processing fee for credit card charges
Which payment option would you like to use?*

Credit CardACHDebit card
Follow these instructionsto initiate monthly payments through Zelle:
1.    Log in to your bank's online banking or mobile app.

2.    Navigate to the Zelle or "Send Money" section.

3.    Initiate a payment to the Zelle recipient.

4.    Choose the "Schedule Payment" or "Recurring Payment" option.

5.    Set the payment frequency, amount, and start date.

6.    Review and confirm the recurring payment details.

7.    The payment will be automatically sent according to your chosen schedule.

I hereby authorize A Little Village Daycare to charge my monthly tuition, daily Flexcare fees, and /or any other costs incurred pursuant to my payment instructions above.

I agree that I will notify A Little Village Daycare, in writing, immediately if my payment method changes in any way and I will provide new paymet information.

In the event that my payment is rejected by my bank or credit card company, or if my payment has not been received by the 5th of the month, I understand that my child will be removed from the schedule until A Little Village Daycare receives payment in full.
Full Name of Signer*

First NameLast Name
Signature*

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Date of Signer*

MonthDayYear
Date
ACH Information:
Bank Name:
Bank Rounting No.:
Bank Account No.:
Account Holder's Name:

First NameLast Name
Account Holder's Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Checking or Savings:

CheckingSavings
I hereby authorize A Little Village Daycare to charge my monthly tuition, daily Flexcare fees, and /or any other costs incurred pursuant to my payment instructions above.

I agree that I will notify A Little Village Daycare, in writing, immediately if my payment method changes in any way and I will provide new paymet information.

In the event that my payment is rejected by my bank or credit card company, or if my payment has not been received by the 5th of the month, I understand that my child will be removed from the schedule until A Little Village Daycare receives payment in full.
Full Name of Signer:*

First NameLast Name
Signature*

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Date of Signer*

MonthDayYear
Date
Credit Card

Visa Mastercard Debit - NO AMEX Credit Card Information (3% Processing Fee on All Credit Card Charges):
Type of Credit Card:

VisaMasterDiscoverOther
Credit Card No.:
Credit Card Expiration Date:

MonthDayYear
Date
Cardholder's Name:

First NameLast Name
Cardholder's Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I hereby authorize A Little Village Daycare to charge my monthly tuition, daily Flexcare fees, and /or any other costs incurred pursuant to my payment instructions above.

I agree that I will notify A Little Village Daycare, in writing, immediately if my payment method changes in any way and I will provide new paymet information.

In the event that my payment is rejected by my bank or credit card company, or if my payment has not been received by the 5th of the month, I understand that my child will be removed from the schedule until A Little Village Daycare receives payment in full.
Full Name of Signer:*

First NameLast Name
Signature*

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Date of Signer*

MonthDayYear
Date
Should be Empty:

A Little Village Montessori DayCare / Preschool

IF YOU WISH TO ENROLL A SECOND CHILD WITH A Little Village DayCare

MOTHER'S INFORMATION

FATHER'S INFORMATION

CHILD'S PREADMISSION HEALH HISTORY - PARENT'S REPORTState of California - Health & Human Resources Agency/California Department of Social Services Community Care Licensing - Form LIC 702 (7/99) (CONFIDENTIAL)

Developmental History (For infants and preschool-age children only) [0-5 years old] Title

Past Illnesses - Check Illnesses that child has had and specify approximate dates of illnesses:

Daily Routines (For infants and preschool-age children only) [0-5 years old]

CONSENT FOR EMERGENCY MEDICAL TREATMENT - CHILD CARE CENTERS OR FAMILY CHILD CARE HOMES State of California - Department of Health & Human Services Agency/California Department of Social Services - Form LIC 627 (9/08) (CONFIDENTIAL)

PARENT CONSENT FOR ADMINISTRATION OF MEDICATIONS [BY ALittleVillageDaycare] AND MEDICATION CHART State of California -[ Health and Human Services/California Department of Social Services, LIC 9221 (8/08)

IMMUNIZATION RECORDS

IDENTIFICATION AND EMERGENCY INFORMATION - CHILD CARE CENTERS/FAMILY CHILD CARE HOMES State of Califonria - Department of Health & Human Services Agency/Department of Social Services Community Care Licensing Division - Form LIC 700 (8.08) (CONFIDENTIAL)

Additional Persons Who May Be Called In An Emergency

Physician or Dentist to Be Called In An Emergency

MARKETING/ADVERTISING

PRICING

Termination

Which program type have you selected:

TERMS AND CONDITIONS - FLEXCARE CLIENTS

TERMS AND CONDITIONS

GENERAL TERMS AND CONDITIONS

PAYMENT AUTHORIZATION

Follow these instructionsto initiate monthly payments through Zelle:

ACH Information:

Credit Card