Enrollment & Agreement/Policy Forms

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1 Enrollment & Agreement/Policy Forms Today s Date Day(s) of Week Care Needed Date Care to Begin Monday Tuesday Wednesday Thursday Friday Time(s) (write in beneath the day to which it pertains) Child s Full Name Address Nickname Date of Birth Place of Birth Phone Child Lives with: Mother Father Both Parents Guardian Marital Status of Parent(s)/Guardian(s): Married Separated Divorced Single Parent Mother s Name and Address Present Occupation Father s Name and Address Present Occupation Guardian s Name and Address Present Occupation Siblings or other children in the household? List names and ages: Home Phone Work Phone Cell Phone Home Phone Work Phone Cell Phone Home Phone Work Phone Cell Phone Other adults in the household? List names and relation to child: Does your child have previous child care experience? Yes No If yes, list dates attended and days and hours per week attended: Child s Physician Phone

2 Physician s Address Child s Dentist Dentist s Address Hospital Preference Phone Phone Insurer Name Policy # Emergency Contacts : PLEASE PROVIDE 2 EMERGENCY CONTACTS Name Relation to Child Phone Address Name Relation to Child Phone Address Unauthorized Pickup: List any special health conditions or concerns or any unusual fears your child has that you feel we should be aware of: Any special eating habits/allergies? What is your child s toilet routine like? Do they use the toilet? How does your child go to sleep? What is your child s nature in a group setting? What is your child s nature when alone or with family? What makes your child angry? How do you handle discipline in your home? How do you expect it to be handled in child care? How do you comfort your child? What are your child s favorite activities? Tell us about your families use of media: What are you seeking in a child care experience for your child?

3 Enrollment Agreement I understand that my child is enrolled at Wow & Flutterville and is scheduled to begin (date & time). I am enclosing the $ registration fee, which covers registration expenses, the required accident insurance fee, and the purchase of equipment. Please make check payable to: Wow & Flutterville or Deanna Cohen. If for any reason I choose not to start on the above date, I must give two weeks notice or I will be charged for two weeks of care for my child. I also agree that if I decide to withdraw my child, I will give two weeks written notice or be billed for the equivalent hours. Emergency Transportation I give permission to Wow & Flutterville to use whatever emergency measures are judged necessary for the care and protection of my child while under their supervision. In case of a medical emergency, I understand that my child will be transported to an appropriate medical facility by the local emergency unit for treatment if the local emergency resource deems it necessary. It is understood that in some medical situations, the staff will need to contact the local emergency resource before the parent, child s physician and/or other adult acting on the parent s behalf. General Field Trip Permission As part of our educational program, we will take the children in our care on a variety of field trips away from the center. The typical destinations of these field trips may include, but are not limited to: (insert the typical destinations of your field trips) walks through the neighborhood walks/drives to the local park, public swimming pool, zoo, etc. walks/drives to the local grocery store, school playground, church playground, local stores, etc. Clients give their consent to these field trips by signing below.

4 Privacy Permission Agreement Our first priority is to protect your child s health and safety. To ensure that we are operating with your full understanding and agreement about your family s privacy, we ask that you grant permission to conduct the following activities. Please check off each item to which you give your consent, and sign below: Placing photos of your child around the center. Giving copies of photos of your children to other families in our care. Placing photos of your child in photo albums for viewing by prospective clients and other families in our care. Using photos of your children in our marketing flyers. Using photos of your children on our Web site. Posting artwork and other crafts that include your child s name around our center. Using an electronic monitor to listen to your child from another room. Listing the name of your child or other members of your family in our client newsletter and posting this information on our bulletin board. Wow & Flutterville Policies: (updated 5/11/15) Wow and Flutterville agrees to care for your child During the period of care Wow and Flutterville will be responsible for the safety, well-being, feeding, rest, attention, warmth and comfort of your child. Wow and Flutterville will provide cloth diapers if you don t currently use cloth for use at the daycare for an additional $3 daily fee. If you do provide cloth diapers we will send them home with your child daily for your laundry. We also ask families to provide a nylon/waterproof dirty bag for soiled clothing so that we may eliminate our use of plastics. Please provide wipes and any diaper cream, sunscreen or teething gels or tablets. Wow and Flutterville will provide wholesome organic vegetarian snacks twice daily. Our lunch program is $2.50 per day; parents may opt out and provide their own lunch. For children who are no longer exclusively drinking mother s milk/formula, we supply: whole fat cow s milk if they are enrolled in our lunch program. Otherwise, juice and milk must be provided by the parents. We try our best to accommodate dietary restrictions and choices, however milk alternatives must be provided by the family as well. We also require parents supply a glass or stainless steel water bottle for daily use. Please provide adequate and labeled weather appropriate clothing for your child s use daily and an extra change of clothing. You are welcome to leave it in her/his tote bag or chubby. Please also make sure your child is wearing playtime friendly clothing that is able to get dirty, as we go outside frequently. Wow and Flutterville will not provide any medications to your child without a doctor s prescription.

5 Over the counter medication does not need a doctor s prescription. However a medication administration form must be filled out by the parent and all medication must be unopened. Please provide a current record of your child s vaccinations for our files. Parent Communication: Parents will have daily opportunity to check in with caregivers about their children at pick -up and or drop-off as long as it doesn t interfere with the caregiver s ability to care for the children in her charge. Parents will receive a daily journal about their child s rest, diaper or toileting, eating and play highlights. You may always Deanna or call on the weekends to discuss your child. It will be our pleasure to discuss them with you if you have questions, comments or concerns on Deanna s off time. She may not be able to get back to you right away as she has her own family Hours of Operation, Fees/Tuition & Closures: Monday-Thursday 8-6 p.m., Friday 8-5 p.m. Fees: Tardy pick up fee $10 per 5 minutes after a 5 minute grace period. Fees due at pick up or next drop off. $2.50 per day for our lunch program Diaper fee is $3 per day if we provide diapers (cloth diapers). Diaper cream, wipes and go home diaper to be provided by parents. $100 one time registration fee (one time fee if siblings are enrolled) $100 non refundable annual supply fee $250 non refundable deposit for final month of care. Final month of care requires a 30 day written notice, with notice this deposit applies to your child's final month of care. $25 tuition late fee for everyday past the grace period due date. 5% sibling discount available on all fees except late fee charges. Rates return to standard if one sibling leaves the care of Wow and Flutterville. $70 to buy an extra day if room is available Tuition: 1 day a week is $285 per month 2 days a week is $545 per month 3 days a week is $805 per month 4 days a week is $1065 per month 5 days a week is $1300 per month Tuition is due on the 1st of every month with a grace period of the 3rd. Please make checks payable to Wow and Flutterville or Deanna Cohen. Wow and Flutterville will be closed and no childcare will be provided on the following legal holidays: The week before Labor Day Labor Day Veteran s Day and Monday before Thanksgiving Day and day after Dec 24-Jan 2nd Martin Luther King Day President s Day Spring Break aligned with the PPS calendar Memorial Day July 4th

6 If your child attends part time and a legal holiday falls on day for his/her care you will still need to pay for the day, as is standard policy for daycares. Wow and Flutterville may be closed in accordance with Portland Public School closure days due to inclement weather. If this is the case, you will be contacted by 6:30 a.m. that morning. Illness Policy: If your child has a fever/vomiting/has diarrhea or a visible rash while under care at Wow and Flutterville, you will be called immediately to come pick your child up from care. If you are not available for pickup within 30 mins we will go through the alternates on your emergency call list. Your child will be separated from other children and kept as comfortable as possible until you arrive. Children must be free of symptoms for 24 hours or have a doctor s note before returning to care. Policy on Termination & Changes to Contract: Wow and Flutterville must receive a 30-day advance written notice to terminate care of your child in order to return your $250 deductible or apply it to your last month of care. Wow & Flutterville may terminate the contract at will without any given notice. Wow & Flutterville also reserves the right to make policy changes at any given time, Parents will be contacted via prior to these policy changes. Policy of Nonviolence: Wow and Flutterville is committed to nonviolence in communications. As such, please refrain from dressing your child in clothing with images of a violent nature or weapons or that degrades people or animals. I understand that Wow and Flutterville reserves the right to refuse admittance of my child if these above policies are not met. I have read and agree to the above policies by Wow and Flutterville.

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