ENROLLMENT AGREEMENT

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1 ENROLLMENT AGREEMENT Completion of this Agreement is required for enrollment. This information is necessary for First Steps Early Childhood Learning Center to comply with the State of Missouri Child Care Licensing Regulations. CHILD INFORMATION First Name: Last Name: Nickname: Date of birth: Current Age: Sex: Home Phone: Siblings: Primary Language: PARENT INFORMATION Primary Parent/Guardian: Driver s License #: Driver s License State: Driver s License Expiration: Other Parent/Guardian: Driver s License #: Driver s License State: Driver s License Expiration: Parent/Guardian Security Questions What is your father s middle name? Answer: *Questions will be used to verify parent/guardian if a pick up authorization is What was the name of your first pet? Answer: called into the Center. Is a restraining order in effect for the non-custodial parent? Yes No First Steps Early Childhood Learning Center must have current court orders on file in order for them to be enforced. EMERGENCY CONTACT AND RELEASE PERSONS (DO NOT INCLUDE PARENTS/GUARDIANS) Please notify the Center if an Emergency Release Person will pick up your child. For the safety of your child, we will request all authorized pick up people with whom staff are not familiar with to provide their Driver s License at the time of pick up. Name #1: Name #2: Name #3:

2 CHILD S MEDICAL HISTORY First Name: Last Name: Date of birth: Hair Color: Eye Color: Height: Weight: Special Medical Conditions: History of serious injuries or hospitalizations of which we should be aware: Diabetes : Yes No Special Dietary Needs: Physical Restrictions: Yes No Explain: Does your child use any special equipment (wheelchair, hearing aid, braces, etc.)? Is your child able to fully participate in all of the activities offered at First Steps? Yes No Explain: Yes No Explain: Is your child able to walk? Yes No Explain: Does your child function at the level of other children in his or her age group? Yes No Explain: Can your child effectively communicate his/her needs? Yes No Explain: Does your child require any assistance at mealtime? Yes No Explain: Is your child toilet trained? Yes No If so, do they need assistance? Please note if your child had any of the diseases listed below: Date Please note your child s illness history. Check all that apply. Chicken Pox Frequent ear infections Mumps Frequent sore throats Rubella (German Measles) Frequent colds/respiratory infections Pertussis (Whooping Cough) Frequent skin rashes Hepatitis Frequent nose bleeds Pneumonia Seizures HIV Fainting spells Scarlett Fever Asthma Other: Other: Please note screening tests performed: Date Vision Medications Hearing Food Please list Allergies and complete Allergy Instruction Form. Speech Other:

3 Substances Foods: Peanuts Other nuts & seeds Citrus fruits Other fruits Cow s milk Yogurt Other dairy Corn Oats Wheat Other grains Yeast Egg yolks Egg whites Soy foods Fish Shell fish Environmental: Dust Mold spores Cats Dogs Other animals Pollen Bee stings Medical: Penicillin Latex CHILD S NAME: ALLERGY INFORMATION MAY Be exposed May NOT be exposed IS allergic Is NOTallergic Not Sure (Check if allergic) Parent(s) Other Family Member Other (please list):

4 MEDICALPOLICIES First Name: Last Name: Date of birth: Prior to enrollment, I must provide the center with updated medical and immunization information for my child. This information must be updated in accordance with the State of Missouri Child Care Regulations and kept current. I understand that children without appropriate current medical records may not attend the center. I agree to promptly provide information to the center regarding any conditions, illnesses, allergies, or other special needs. When a child becomes ill, he/she will be isolated from the other children, and the parent will be notified to pick up the child within an hour. If the parent cannot be reached, we will contact the person indicated by you on your child s emergency care form. If my child contracts a reportable communicable disease, my child may return only with a physician s note indicating that my child is no longer contagious. In the event of a serious accident, parents will be notified as soon as possible. First Steps will seek emergency treatment for the child by dialing 911. First Steps will not transport the child to the hospital; this will only be done by ambulance. I authorize First Steps to consult the physician/dentist named if parents cannot be reached. Payment for this care/treatment is the responsibility of the parents. Physician s Name: Name of Practice: Phone Number: Dentist s Name: Name of Practice: Phone Number: MEDICATION I authorize First Steps Early Childhood Learning Center to administer to my child non-prescription/prescription medications as needed, according to the dosage instructions on the medication container. I will provide written authorization for First Steps Early Childhood Learning Center to administer the medication in accordance with written instructions from the child s healthcare provider or me, as required. I will complete necessary authorization forms and understand that the prescription label instructions must be followed. I will provide the medication in its original container with the pharmacist s label. NAP COTS FOR CHILDREN AGES MONTHS All children will have a rest period each day. I give permission for my child to sleep on a cot during rest time. I understand that First Steps Early Childhood Learning Center is responsible for providing clean bedding weekly and as needed. I DO NOT give my child permission to sleep on a cot during rest time. I will provide a nap cot for my child to sleep on. ACKNOWLEDGEMENTS I have received a copy of this facility s polices pertaining to the admission, care, and discharge of children. I have been informed that a copy of the Licensing Rules for Child Care Homes and Centers is available at this facility for review. The provider and I have agreed on a plan for continuing communication regarding my child s development, behavior, and individual needs. When my child is ill, I understand and agree that s/he may not be accepted for care or remain in care. On occasion the facility may take my child on a walking excursion. I DO give permission for the facility to take my child on a walking excursion. I DO NOT give permission for the facility to take my child on a walking excursion.

5 CENTER HOURS OF OPERATION First Steps Early Childhood Learning Center is open from 6:30 a.m. 6:30 p.m. Monday through Friday. The center will be closed in recognition of various holidays throughout the year. I have been provided with a list of holiday closings. There is no reduction in tuition as a result of scheduled and bad weather closures. If I or other authorized persons fail to pick up my child and/or contact the center, and I or other persons cannot be reached, center staff, within one hour of closing time, may release children to the custody of child protective services or local authorities. TUITION AND FEES I understand that my weekly tuition fees are Child: Tuition: $ Discount: $ Net Tuition:$ as follows: A nonrefundable annual registration fee of $ is due at the time of enrollment and payable each year by September 1 st. First Steps Early Childhood Learning Center policy requires a contracted, set schedule for your child with a minimum of 2 days per week. If the necessity arises for additional days not previously scheduled for your child, First Steps Early Childhood Learning Center will accommodate additional days based on space availability. Payment for the additional days will be made at your contracted daily rate. Following five (5) occurrences of early drop-off or late pick-up you will be asked to permanently change your schedule to reflect your pick-up/drop- off time.reservation forms are available in the office to request a schedule change or extended leave. Notice is required two-weeks in advance to change your child s schedule, and in order to be eligible for the extended leave discount. You may change your child s schedule once in a calendar year without any charges. An administrative fee of $20 per change will be charged for each change thereafter. I agree to pay full tuition even if my child is absent for one or more days. Tuition fees are not subject to pro-ration for illness, holidays, or emergency closure of the center. Vacation leave: for each full calendar week my child is absent, the tuition fee will be discounted 50% as a reservation fee. I understand I will ONLY receive 2 vacation weeks per year and the payment for reservation fees should be made in advance. The center requests a two-week notice of an intended vacation. After 2 weeks have been discounted, full tuition will be due for any additional weeks of vacation. Please contact the center for more information on Extended Leave Discounts. Vacation and Extended leave discounts are ONLY available to children enrolled full-time. A late pick-up fee of $1.00 per minute per child will be assessed when a child is left beyond the center s operating hours. The late pick-up fee does not constitute an agreement to provide after-hours service, nor will the late fee be applied toward tuition. Chronic late pick-up may be grounds for termination of services. Weekly tuition is due by 6:30 p.m. on the Friday prior to services rendered. Tuition paid monthly is due by 6:30 p.m. on the 1st business day of each month. If tuition is not paid in advance as listed above, a late fee of $25 will be charged. Tuition checks that are returned by our financial institution for non-sufficient funds will be assessed an additional check charge of $25 per check and $25 late fee. A delinquent account jeopardizes your child s care space. First Steps Early Childhood Learning Center reserves the right to discontinue care for your child when tuition is in arrears for more than one week. In the event that my account is sent to collections, I will be responsible for the balance of my account and any reasonable collection of attorney fees and costs associated with the collection of the account. In the event that you find it necessary to cancel your child care, you must give a written and dated notice of cancellation to the Center Director two-weeks prior to such termination of services. A fee equivalent to two-weeks of child care tuition will be charged in the event timely notice is not received. You will be required to bring your account up to date. My child may have the opportunity to participate in special programs/field trips. This may result in an additional fee due before the day of the event and may require completion of a specific permission slip. SCHEDULED ATTENDANCE I understand that a change in this schedule must be made in writing and may require a new Enrollment Agreement. DAY TIME IN TIME OUT Monday Tuesday Wednesday Thursday Friday Parent/Guardian s Signature: Director s Signature: Date: Date:

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