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  Child Enrollment Application   
Child’s Information : 
 Name:_______________________   Date of Birth: ___/____/____  Full Address: _______________________________________________________Desired Start Date: __________  Primary Language: ____________ Enrollment Date:______________   Withdrawal: _______________Child Description: 
Eye Color: _______________  Hair Color:__________ 
Sex: _________________ Height: __________________ 
Weight: _________        Race:_________________ Identifying Marks:_____________________________________ 
Child’s attendance Schedule: (indicate daily arrival and departure time in space next to days) Daily Arrival Time
Mon_____ Tues_____ Wed_____  Thurs _____ Fri_____  Sat_____Daily Departure Time: 
Mon_____ Tues_____ Wed_____ Thurs_____  Fri____Sat_____ Weekly Fee: $____   Bi-Weekly Fee:$______  Monthly Fee:$_______  Make sure to check:   
Breakfast __Lunch_____PM Snack_____  AM Snack__ Supper______ 
 
In return for services I received, I Agree to pay the amount above, in ADVANCE to The Shining Stars Academy. I have read and accepted the policies of The Shining Stars Academy and release it from my liability for illness or injuries resulting from conditions or circumstances beyond its control. I also give permission for my child to participate in water activities when under school supervision. I will leave my child under the supervision of the staff member and understand that my child will be released to only me or person(s) authorized. I plan to leave my child at The Shining Stars on the days and time indicated above.     
Parent/ Guardian Information : 
 Name:________________     Name: ____________________ TDL:__________________   TDL:___________________ Relationship:____________ Relationship:______________________  Address:_______________ Address:_____________________ ___________________   _______________________________ _____________________ _________________________________  Email:__________________
 Home Phone:____________   Home Phone:____________________  Cell Phone: _____________   Cell Phone: _______________
Parent / Guardian Work Information: 
 Company Name: ___________ Company Name: _____________ Address:_________________Address:________________________ ______________________________________ 
 Day Time Phone:_________Day Time Phone:__________________ Fax Phone: _____________ Fax Phone: _____________________ Email: ______________Email:_______________________________  Social Security #: ____-____-____Social Security ____-____-____ Parent’s Martial Status:
___ Married   ____  Divorced ____ Separated ____ Single ____ Other 
 
Child Legal Guardian(s): 
___ Both Parents___ Mother __ Father  ___Foster Parent___OtherChild Living Arrangements: 
___ Both Parents ____ Mother ___ Father___ Foster Parent__OtherEmergency Contacts : 
 Name: ______________    Name: _______________________ TDL:_________________    TDL:______________________ Relationship:____________   Relationship:_________________ Address:_______________Address:_______________________ ________________________     ________________________ Email:________________Email:____________________________ Home Phone:_____________ Home Phone:____________________ Day Time Phone:___________Day Time Phone:_________________
Cell Phone:_______________  Cell Phone: _____________________  Pick Up Authorization: 
Name: _________________ Name:__________________
TDL:____________________TDL:___________________________Relationship: ______________Relationship:____________
Address:_______________ Address:___________________ ____________________ _____________________
Email:_______________Email:___________________________ Daytime Phone:__________  Daytime Phone:__________________ Home Phone:_____________ Home Phone:_________________
Cell Phone: _______________Cell Phone:______________________  Trips & Activity Permission:
 I do ____ do not ____ give permission for my child to participate in field trips with The Shining Stars Academy under the supervision of a qualified teacher. I will be notified when such trips are to take place. 
 I do ___ do not ___ give permission for my child to participate in walks outside if weather is permissible to the park or fenced in playground.   
School Age Children: My child attends the following school and his/her immunization records are on file at the school and all immunizations and tuberculosis tests are current. Name of School:__________ Phone Number: _________________ 
Parent/ Guardian Sign:____________________________________Photo Permission: 
Photo Permission:        Sign: _________________    Yes      No 
Observation Permission: Sign: _________________     Yes      No Computer use (Educational no internet)     Sign:_____   Yes      NoAuthorization for Emergency Medical Care: I understand that I will be notified immediately in case of an emergency accident, illness or other injuries requiring medical attention for my child, and I will make arrangements for medical care with a physician or hospital of my choice. My Child is enrolled in an ongoing health supervision program with an annual evaluation. If I am not available or time does not prevail, or in a critical emergency requiring immediate medical care, I hereby authorize The Shining Stars Academy for the following:
  1. I give permission for my child to receive CPR in necessary. 
 Sign ____________________________
  1. I give permission for my child to receive First Aid and emergency medical care if necessary.
Sign _____________________________ Admission Requirements: One of the following must be presented whrn your pre-school age child is admitted to the Child Care Facility or within one week of admission. Check to indicate the option you select: 
 _____  Doctor’s Statement: I have examined the above named child within the past year and find the he/she is physically able to take part in the Child Care Program. 
 _____  A copy of the medical screening form of the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program, if no referral for further diagnosis and treatment is indicated. 
 ______ A form or written Statement from a health service of clinic.   
 
IF I DO NOT HAVE THE ABOVE: 
 _____ PARENT’S STATEMENT: My child has been examined within the past year by a licensed physician and is able to participate in the child care program. An associate of The Shinning Stars Academy has my permission to administer Tylenol liquid, tablets, or the following aspirin substitutes (parent(s) must provide the medication): 
Please list any allergies, illness or injuries that affect your child’s level of participation: including Chronic Health Issues________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 
 Name of Physician/Clinic:____________________  Phone:________________________ Address:________________________________________________________________ 
Hospital Preference:________________________Phone:_________________Address:________________________________________________________________ 
Note: if your child has a fever, diarrhea or vomiting, he or she will not be accepted at the center before 24 hours has passed since they became ill. If child has a communicable disease such as Chicken pox, measles, mump, ringworms, German measles, shigellosis, scarlet fever, etc; they will not be accepted back at the center without a statement from a physician. 
  School Agers Authorization Form: 
 School Name: ___________________________________________ Grade:______ Teacher: ______________ 
Transportation _____ AM______PM_______ One Way __________           Round Trip_________________________ 
 Parent/ Guardian Sign:____________________________________________    
 Parent Handbook Signature Page: I have received, read and understand the policies of the parent handbook.   I have read and understand the policies of the Non-Discrimination and civil right statements section in the parent handbook of The Shining Stars Academy.   Parent/Guardian Sign: _____________Director/Assistant Sign:________________ 
Parent Printed Name: ____________________________________      Parent Signature:__________________________________ Date:_________________ 
Parent Printed Name: ______________________________________________________      Parent Signature: __________________________________ Date:__________________ 
  For Center Use ONLY: Class:______________ 
Admission Date:__/____/___Age at Admission:_____________ 
 Date Registration Fee received: _________ 
 Director / Assistant Signature: _____________________________    ©2010
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