EARLY CHILDHOOD EDUCATION CENTER ENROLLMENT FORM 55 PA CODE CHAPTERS 3270 123 & 181 (C): 3280 123 & 181 (C): 3290 123 & 181 (C) CHILD S FIRST NAME MIDDLE NAME LAST NAME BIRTH DATE START DATE WITHDRAWAL DATE PLANNED DAILY ARRIVAL TIME PLANNED DAILY PICKUP TIME TUITION FEE (for service from 7:00AM - 5:30PM) INFANT TUITION $230 (6-12 mo.) OLDER TODDLER TUITION $220 (25-47 mo.) YOUNG TODDLER TUITION $225 (13-24 mo.) PRE-KINDERGARTEN WEEKLY $215 (48 mo. to date child enters Kindergarten) PAYMENT SCHEDULE (choose one) WEEKLY BI-WEEKLY TYPE OF ACCOUNT (money orders are the method of payment accepted) PRIVATE PAY CCIS PAYMENT, FEES, & CHARGES I understand the services to be provided as part of the day care fee are for educational instruction, developmentally appropriate care, meals for children, special events, laundering sheets and blankets. I agree to pay weekly every Friday before 12pm by putting the payment inside the drop box located inside the center by the front door. I understand one week of unpaid overdue of unfulfilled results in an immediate termination of service. I agree to pay the full tuition fee even if my child is absent for one or more days. Tuition is not subject to discounts for holidays, professional development training, emergency closures (i.e. weather), sick days or doctor appointments. I agree to pay a late pickup fee of $25 (per child) when tuition is not received on time by Friday before 12pm. I understand the late fee charge will be waived if the center is notified of child s absence in advance and the payment is paid in full on the day of the child s return. I agree to pay a late pickup fee for every 10 minute, per child, if my child is not picked up before closing ($25 for first 10 minutes and $10 for each 10 minutes thereafter). I agree to pay weekly the difference when CCIS subsidy does not covered the full amount of weekly tuition. As a CCIS recipient, I agree to pay the provider the daily rate when my child exceeds the allotted 25 days of absence. I agree to pay the weekly tuition rate when I am ineligible for CCIS or suspended. I agree to update the Emergency Contact/Parental Consent Form information whenever changes occur or every 6 months at a minimum (3270 124, 3280 124, 3290 124). I understand vacation time is available for families in accordance with the center s vacation policy. I understand the 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. MEDICAL POLICIES & PROCEDURES Prior to enrollment, I will provide the center with updated medical and immunization information for my child. This informationis to be kept current and updated in accordance with state child care regulations. I agree to provide information to the child center about my child s conditions, illnesses, allergies or other needs. 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. 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 a pickup no later than 2 hours after being contacted. If I cannot be reached, the staff will contact those individuals listed in the Emergency Contact and Release. A child may come to school from a doctor s appointment if they have a doctor s notes and arrive by 11:00am. FORM OF PAGE 1
EARLY CHILDHOOD EDUCATION CENTER ENROLLMENT FORM 55 PA CODE CHAPTERS 3270 123 & 181 (C): 3280 123 & 181 (C): 3290 123 & 181 (C) OPERATING HOURS POLICIES & PROCEDURES Regular operating hours are Monday through Friday from 7AM - 5:30PM. The dropoff/arrival time is between 7AM - 9AM. Any dropoff or arrivals after 9AM must be communicated to the ECEC office supervisors at 215 558 1511. This policy is in place to minimize disruptions in the classroom and to support classroom instruction time. Meals are served during the following times: Breakfast, 7:30AM - 9AM; Lunch, 11AM - 12:30PM; Snack 2:30PM - 3PM. Bringing food from home is not permitted in the facility/classroom with the exception of infant food/formula. Please acknowledge the following days when the center is closed or operating with modified hours due to holidays and professional development days (There is no reduction in tuition as a result of these center closures or any emergency closure): INDEPENDENCE DAY CLOSED LABOR DAY CLOSED THANKSGIVING DAY CLOSED DAY AFTER THANKSGIVING CLOSED CHRISTMAS EVE / OPEN 7AM - 2PM CHRISTMAS DAY CLOSED NEW YEARS EVE / OPEN 7AM - 2PM NEW YEARS DAY CLOSED MONDAY AFTER EASTER CLOSED MEMORIAL DAY CLOSED PROFESSIONAL DEVELOPMENT DAYS (TBD - 5 additional days may be required) ELECTRONIC DATA, DEVELOPMENTAL SCREENING & ASSESSMENTS In Pennsylvania, the Office of Child Development and Early Learning provides funding to a variety of statewide early education programs which are PA Keys STARS Child Care Centers such as ours. Electronic data systems are needed to maintain individual child records and to collect data for improving early childhood porgrams. I understand and give consent to complete a developmental screening, assess, maintain individual child records and collect data about my child. FAMILY HANDBOOK ACKNOWLEDGEMENT I received complete written program information at the time of enrollment (3270.121, 3280.121, 3290.121). I understand and agree that it is my responsibilty 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. TO BE SIGNED ON-SITE / IN PERSON CONTRACT APPROVAL I certify that I have read, understand and accept all of the terms and conditions described in this Enrollment Agreement. PARENT S NAME DATE PERIODIC REVIEW To be completed every 6 months PARENT S NAME DATE FORM OF PAGE 2
EARLY CHILDHOOD EDUCATION CENTER PARENTAL CONSENT FORM Completion of this agreement is required for enrollment. This form will enable us to better understand your child and meet his/her needs. Much of the information requested is necessary to comply with state child care licensing regulations. CHILD ENROLLMENT INFORMATION FIRST NAME MIDDLE NAME LAST NAME HOME ADDRESS STATE ZIP NICKNAME BIRTH DATE ADMISSION DATE SEX EYE COLOR HAIR COLOR MOTHER S NAME/LEGAL GUARDIAN PARENT/GUARDIAN/SPONSOR HOME ADDRESS (if different than child s) STATE ZIP HOME EMAIL HOME PHONE WORK EMAIL EMPLOYER EMPLOYER ADDRESS CELL PHONE WORK PHONE STATE ZIP WORK HOURS FATHER S NAME/LEGAL GUARDIAN PARENT/GUARDIAN/SPONSOR HOME ADDRESS (if different than child s) STATE ZIP HOME EMAIL HOME PHONE WORK EMAIL EMPLOYER EMPLOYER ADDRESS CELL PHONE WORK PHONE STATE ZIP WORK HOURS Are there any visitation restrictions you wish to notify us of? YES NO MEDICAL INFORMATION PRIMARY PHYSICIAN S NAME PRACTICE NAME PHONE PRACTICE ADDRESS STATE ZIP CHILD S HEALTH INSURANCE PROVIDER POLICY # SECONDARY HEALTH INSURANCE PROVIDER POLICY # FORM OF PAGE 3
EARLY CHILDHOOD EDUCATION CENTER PARENTAL CONSENT FORM Completion of this agreement is required for enrollment. This form will enable us to better understand your child and meet his/her needs. Much of the information requested is necessary to comply with state child care licensing regulations. EMERGENCY CONTACT PERSONS & RELEASE INFORMATION (do not include parents/guardians/sponsors) As the parent/guardian/sponsor, I authorize The Salvation Army to release my child(ren) to the person(s) designated below. This is in consonance with The Salvation Army Emergency Plan & Release Policy and Procedure. I understand the staff will only release my child to those persons listed below. If I want a person who is not identified below to pick up my child, I must notify the office supervisors in advance at 215 558 1511. My child will not be released without prior authorization and proper identification. I will notify the center if an Emergency Release Contact will pick up my child on a given day or understand it is my responsibility to maintain current contact information. CONTACT #1 HOME ADDRESS STATE ZIP CONTACT #2 HOME ADDRESS STATE ZIP CONTACT #3 HOME ADDRESS STATE ZIP AUTHORIZATION CHECKLIST (Parent s initial is required for each item below to indicate parental consent) OBTAINING EMERGENCY MEDICAL CARE ADMINISTER MINOR FIRST AID PROCEDURE WALKS & TRIPS SWIMMING TRANSPORTATION BY THE FACILITY WADING PHOTO CONSENT AGES & STAGES SCREENING FORM OF PAGE 4
MEDICAL, DEVELOPMENTAL HISTORY & SPECIAL NEEDS Please attach a copy of your child s most recent physical as well as any instructions or specific information from your physician that will help us better care for you child. DOES YOUR CHILD... HAVE ANY OF THE FOLLOWING SPECIAL MEDICAL CONDITIONS OR CHRONIC ILLNESSES? ASTHMA DIABETES SIEZURES ECZEMA OTHER NONE REQUIRE MEDICATION(S) FOR MEDICAL CONDITIONS OR CHRONIC ILLNESS? YES NO HAVE ANY SPECIAL EQUIPMENT FOR A MEDICAL CONDITION OR CHRONIC ILLNESS? YES NO HAVE ANY ALLERGIC REACTIONS TO THE FOLLOWING? FOOD MEDICATION ENVIRONMENT OTHER NONE HAVE ANY DIETARY RESTRICTIONS? YES NO HAVE ANY OF THE FOLLOWING SPECIAL NEEDS? VISION HEARING SPEECH COGNITIVE FINE MOTOR GROSS MOTOR SOCIAL EMOTIONAL/BEHAVIORAL OTHER NONE FUNCTION AT THE DEVELOPMENTAL LEVEL OF OTHERS HIS/HER AGE? YES NO HAVE ANY IEP/IFSP? YES NO HAVE A THERAPIST(S) OR OTHER SUPPORT SERVICES? YES NO HAVE TOILET TRAINING? YES NO Is there any information about this child s health, special needs or development, that this school would need in the event of an emergency? A physical assessment form must be printed out and completed by the child s primary physician. A link to the document can be found here. FORM OF PAGE 5