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:__________________
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:
- I give permission for my child to receive CPR in necessary.
- 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:________________________________________________________________
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