Child's Information *
Age * Sex * Child's Primary Language * Parents Primary Language * Child's Home Address * City * State * ZIP * Does Your Child Attend School? * School Name Grade School Phone School Address * Drop Off Time Pick Up Time Family Information *
Parent/Guardian/Sponsor * Relationship To Child * Home Phone * Cell Phone * Home Address (if different from above) * City * State * ZIP * Home Email Work Email Work Phone Employer Employer Address City State ZIP Work Hours Other Guardian Relationship To Child Home Phone Cell Phone Home Address (if different from above) City State ZIP Home Email Work Email Work Phone Employer Employer Address City State ZIP Work Hours Relationship To Child Home Phone Cell Phone Home Address City State ZIP Home Email Work Email Work Phone Employer Employer Address City State ZIP Work Hours Relationship To Child Home Phone Cell Phone Home Address City State ZIP Home Email Work Email Work Phone Employer Employer Address City State ZIP Work Hours Relationship To Child Home Phone Cell Phone Home Address City State ZIP Home Email Work Email Work Phone Employer Employer Address City State ZIP Work Hours Birth date Height Weight Hair Color Eye Color Distinguishing Marks 1. Does your child have any special medical conditions? □ No □ Yes Explain
Child’s Medical & Developmental History
2. Does your child have any chronic illnesses? □ No □ Yes Explain 3. Please list a brief history of your child’s serious injuries and hospitalizations. 4. Does your child have diabetes? □ No □ Yes If yes, please attach care instructions from your physician. 5. Does your child have asthma? □ No □ Yes If yes, please attach care instructions from your physician. 6. Will medication be administered regularly? □ No □ Yes If yes, please attach care instructions from your physician. 7. Does your child have any special dietary needs? □ No □ Yes Explain 8. Is your child able to fully participate in all activities? □ Yes □ No Explain 9. Does your child have any physical restrictions? □ No □ Yes Explain 10. Does your child function at the level of other children in his/her age group? □ Yes □ No Explain 11. Is your child able to walk □ Yes □ No 12. Can your child communicate his/her needs? □ Yes □ No 13. Does your child need assistance at meal time? □ No □ Yes Explain 14. Does your child rest during the day? □ No □ Yes 15. Is your child toilet trained? □ No □ Yes 16. Does your child use any special equipment, such as breathing machine, wheelchair, hearing aid, braces, glasses etc? □ No □ Yes Explain 17. Does your child require one-to-one care/supervision on a regular basis for a significant period of time? □ No □ Yes Explain 18. Does your child requires any accommodations or modifications to fully and equally enjoy participating in a group care setting? □ No □ Yes Explain Illness History (please check all that apply)
Please attach care instructions from your physician for any of these illnesses.
Other Illness History Disease History (please check all that apply and add the date) List down all that apply above and add the date Medication Allergies
Allergies (please list)
Reaction Food Allergies
Allergies (please list)
Reaction Bee Stings Allergies
Allergies (please list)
Reaction Respiratory Allergies
Allergies (please list)
Reaction Other Allergies Reaction Are any of these allergies life-threatening?
Please attach care instructions from your physician for any life-threatening allergies.
Miscellaneous Screenings and Tests (please check all that apply and add the date of last screening) List down all that apply above and add the date Birth date Primary physician’s practice name Phone Physician’s practice address City State ZIP Preferred hospital/clinic for emergency care City State Dentist’s name Dentist’s practice name Phone Dentist’s practice address City State ZIP Policy number Secondary health insurance provider name Policy number Child’s Immunization History (please attach a copy of your child’s immunization records)
Above is a list of immunizations that your child may have received. Immunizations in checkmark are required by our state. [Check with your state requirements. You may do this at http://www.nnii.org/vaccineInfo/index.cfm#state Check any immunization below that is a requirement.]
Attached here the link of your child's immunization records (Google Drive, Dropbox, Onedrive, iCloud) 1. Prior to enrollment, I must provide the center with updated medical and immunization information for my child. This information is to be kept current and updated in accordance with state child care regulations.
Additional Medical Policies
2. I agree to provide information to the child care center about my child’s conditions, illnesses, allergies or other needs. 3. If my child becomes ill with a reportable contagious disease, I understand that he/she will not be able to return until I bring in a physician’s note stating that he/she is no longer contagious. 4. If my child becomes ill during his/her time at the child care center, the staff will contact me to pick up my child. I will arrange for pick up as soon as possible and no later than one (1) hour after being contacted. If I cannot be reached, the staff will contact those listed in the Child Emergency Contact and Release. In case of a medical emergency, the staff will attempt to contact me, those listed in the Child Emergency Contact and Release, and lastly my physician.
Emergency Medical Authorization & Consent
In case of a medical emergency, I agree that my child may receive first aid and/or CPR by trained staff at UCCLC/ULA. In case of a medical emergency, I permit the transportation of my child to a local hospital or other urgent care facility, if necessary by paramedics or other emergency personnel. In case of a medical emergency, I will be responsible for the emergency medical expenses. I give my permission to this center to apply □ sunscreen and □ insect repellant to my child. Please check which product you will permit.
Application of Sunscreen & Insect Repellant Authorization
I understand that I must supply my own sunscreen and/or insect repellant with a valid expiration date, and it will be labeled with my child’s name. I have special instructions for the application process. Birth date Hours of Operation
Regular operating hours are Monday through Friday from 6:00 AM to 6:00 PM except closings for various holidays, and inclement weather as described in the Family Handbook. Please consult the current calendar for holidays. There is no reduction in tuition as a result of center closures.
The procedure to notify families should severe weather or other conditions prevent the program from opening on time or at all will be announced on radio station ____107.7(WPRW-FM)_____. If it becomes necessary to close early, we will contact you or someone listed in the Emergency Contact and Release, and it will be your responsibility to arrange for your child’s early pick up.
Enter the days and hours that you wish to contract for child care
I would prefer to make tuition payments on a My child will participate in the following meal plan Starting on ___________________ a fee of $_______is due
Fee Policy (to be completed by staff; reviewed and initialed by the parent/guardian/sponsor after completion)
A fee of $___________ is paid by GACAPS on a weekly basis Tuition is due and payable on the Tuition is not subject to discounts for holidays, emergency closures (i.e., weather), or absence other than hospitalization, contagious illness, or absence at the request of a doctor (a written doctor’s note is required to receive credit). I agree to pay the full tuition in advance of services rendered. - I agree to pay the full tuition fee even if my child is absent for one or more days. A late fee of $10.00 is due if tuition is not received on time. A non-refundable registration fee of $65.00 is due yearly. A late pick-up fee of $1.00 per minute per child (not to exceed $15.00 per child) is due if my child is not picked up before closing. Accounts two weeks in arrears may result in immediate termination of service. My child may have the opportunity to participate in a special program or field trip that may have an additional fee due before the day of the event. A specific permission slip may be required. All returned checks will be charged a fee up to the maximum amount allowed by law. Two or more returned checks will result in my account being place on “money order only” status. A receipt for income tax purposes X will □ will not be provided. Any arrangement/employment between me and staff of this center (i.e., babysitting), outside of the programs and services offered by this center, is an individual endeavor and private matter not connected or sanctioned by this center. This center shall remain harmless from any such arrangement.
Private Employment Acknowledgement and Release
Occasionally, photos will be taken of the children at the center for use within the center or on our website. Please indicate that you authorize the use and reproduction of photographs of your child in conjunction with the program.
I give my permission for my child to participate in supervised walking excursions near and around the center. UCCLC/ULA agrees to obtain written authorization from me before my child participates in routine transportation, field trips, special activities away from the facility, and water-related activities occurring in water that is more than two (2) feet deep.
I understand and agree that it is my responsibility to read and familiarize myself with policies and procedures outlined in the Family Handbook and agree to abide by them.
I understand that it is my responsibility to go directly to management with any questions I may have regarding the policies and procedures and information contained in this Enrollment Agreement. Information contained in the Family Handbook may be subject to change. I certify that I have read, understand, and accept all of the terms and conditions described in this Enrollment Agreement and the Family Handbook.