(4th Child) – Life Centered Enrollment Form

If you have more than one child, you must complete a separate form. However, we have completed much of this form for you with the information provided for your first child. Be sure to review the form carefully and complete or correct the additional information.

"*" indicates required fields

Completion of this agreement is required for enrollment. It will allow us to better understand your child's needs and comply with state child care licensing regulations. Please have medical instructions and proof of immunizations REQUIRED by our state available to upload. -- IMPORTANT. If you need more time to complete this form, scroll to the bottom and click "Save and Continue Later" **All information provided is sent through a Secure Sockets Layer (SSL) and encrypted for security.

Tiny Toes
For Infants and Toddlers
Hours: 6:00am – 5:30pm

Pre-K CPP Program
For 4 year olds
Hours: 6:00am – 5:30pm

Preschool
For 2 1/2 - 7 years olds
Hours: 7:00am – 5:30pm

School Age
For 5 - 12 year olds
Hours: 6:00am – 5:30pm

ENROLLMENT INFORMATION

4th Child's Information

Which Life Centered Program are you enrolling your 4th child in?*

TINY TOES

PRE-SCHOOL

PRE-K CPP

SCHOOL AGE

4th Child Full Legal Name*

Full Name

4th Child’s nickname:

Nickname

4th Child's Age:*

4th Child's Sex:*

4th Child's Birthdate:*

Parent/guardian/sponsor's primary language:*

4th Child’s primary language:*

4th Child’s home address:*

Street Address City State ZIP Code

Upload a photo of your 4th child here:

(optional)

Drop files here or

Max. file size: 256 MB, Max. files: 2.

Does your 4th child attend school?*

Yes

School name:*

Grade:*

School Phone:*

Family Information

List family members & pets your 4th child lives with – include first names, relation and ages of siblings:*

Example: The child listed above lives with her mother and her father. The child has no siblings. She has one pet cat.

Parent/Guardian/Sponsor Information

Parent/guardian/sponsor's name:*

Relationship to 4th child:*

Home phone:*

Or best contact phone number

Cell/Mobile phone:*

Or best contact phone number

Home email:*

Best contact email address

Does the parent/guardian/sponsor live in the same home as the 4th child?

Yes

What is the Paret/Guardian/Sponor's home address?*

Street Address City State ZIP Code

Is the Parent/Guardian/Sponsor of the 4th child currently employed?

Yes

Employer:*

Work email:*

Work phone:*

Employer address:*

Street Address City State ZIP Code

Work hours:*

Example: 9am - 5pm

4th Child Emergency Contact and Release Information (do not include parents/guardians/sponsors)

Please notify the center if an Emergency Release Contact will pick up your child on a given day. [For the safety of your child, we request that all authorized pick up persons with whom staff is not familiar provide a photo ID at the time of pickup.]

Emergency Contact #1

Person's name:*

Relationship to child:*

Home phone:

or best contact phone number

Cell/Mobile phone:*

Or best contact phone number

Home address:*

Emergency Contact #1's home address

Street Address City State ZIP Code

Home email:*

Emergency Contact #1's email

Is emergency contact person #1 employed?*

Yes

Work email:*

Work Phone:*

Employer:*

Emergency Contact #1's Employer

Address

Street Address City State ZIP Code

Work hours:*

Would you like to list a #2 emergency contact person?*

Yes

Emergency Contact #2

Person's name:*

Relationship to child:*

Home phone:*

Or best contact phone number

Cell/Mobile phone:*

Or best contact phone number

Address

Street Address City State ZIP Code

Home email:

Is emergency contact person #2 employed?*

Yes

Work email:*

Work phone:*

Employer*

Address*

Street Address City State ZIP Code

Work hours:*

Would you like to list a #3 emergency contact person?*

Yes

EMERGENCY CONTACT #3

Person's name:*

Relationship to child:*

Home phone:

Cell/Mobile phone:*

Address*

Street Address City State ZIP Code

Home email:

Is emergency contact person #3 employed?

Yes

Work email:*

Work phone:*

Employer:*

Employer address:*

Street Address City State ZIP Code

Work hours:*

The persons designated in this section will be contacted by us if you cannot be reached in the event of a medical or other emergency. Our staff will only release your child to you or to those persons listed above. If you want a person who is not identified above to pick up your child, you must notify our staff in advance, in writing. Your child will not be released without prior written authorization.

Parent initial:*

Staff Initial __________________________
(Office Use Only)

Date*
Month
Day
Year

MEDICAL INFORMATION

4th Child's Name*

4th Child' Birth date:*
Month
Day
Year

Distinguishing marks:*

Height:*

Weight:*

Hair color:*

Eye Color:*

4th Child’s Medical & Developmental History

1. Does your 4th child have any special medical conditions?*
Yes
No

Explain special medical conditions:*

2. Does your 4th child have any chronic illnesses?*
Yes
No

Explain chronic illnesses:*

3. Please list a brief history of your child’s serious injuries and hospitalizations.*
If they have none, write N/A

4. Does your 4th child have diabetes?*
Yes
No

5. Does your 4th child have asthma?*
Yes
No

6. Will medication be administered regularly?*
Yes
No

If you answered yes to any of the medical conditions listed above, please upload care instructions from your physician here.*
Drop files here or
Max. file size: 256 MB, Max. files: 10.

7. Does your 4th child have any special dietary needs?*
Yes
No

Eplain dietary needs:*

8. Is your 4th child able to fully participate in all activities?*
Yes
No

Explain why your 4th child CAN NOT fully participate in all activities.*

9. Does your 4th child have any physical restrictions?*
Yes
No

Eplain what 4th child's physical restrictions:*

10. Does your 4th child function at the level of other children in his/her age group?*
Yes
No

Eplain why your 4th child DO NOT function at the level of other children in his/her age group:*

11. Is your 4th child able to walk?*
Yes
No

12. Can your 4th child communicate his/her needs?*
Yes
No

13. Does your 4th child need assistance at meal time*
Yes
No

Eplain what assistance your 4th child needs at mealtime:*

14. Does your 4th child rest during the day?*
Yes
No

15. Is your 4th child toilet trained?*
Yes
No

16. Does your 4th child use any special equipment, such as breathing machine, wheelchair, hearing aid, braces, glasses etc?*
Yes
No

Eplain your 4th child's use of special equipment:*

17. Does your 4th child require one-to-one care/supervision on a regular basis for a significant period of time?*
Yes
No

Eplain how your 4th child requires on-to-one care/supervision on a regular basis for a significant period of time:*

18. Does your 4th child require any accommodations or modifications to fully and equally enjoy and participate in a group care setting?*
Yes
No

Eplain how your 4th child requires accommodations or modifications to fully and equally enjoy and participated in a group care settings:*

Illness History

Please check all that apply (Illness history)*
Vision problems
Nosebleeds
Seizures
Hearing problems
Skin rashes
Mouth sores
Constipation
Sore thoats
Fainting
Diarrhea
Ear infections
Persistent cough
Asthma/breathing problems
Urinary tract infections
Other

If you selected Other from above, explain below:*

Please upload care instructions from your physician for any of the illnesses listed above..*
Drop files here or
Max. file size: 256 MB.

Disease History

Please check all that apply (Disease History)*
Chicken Pox (Varicella)
Bronchiolitis
Botulism
Measles Rubella
Pneumonia
Haemophilus Influenza
Rubella (German Measles)
Pertussis (Whooping cough)
Meningococcal Infection
Mumps
Tetanus
Rabies
Scarlet Fever
Diphtheria
Bacterial Meningitis
COVID 19
NONE OF THESE (N/A)

If you selected any of the illlnesses above, please upload care instructionss from your physician.*
Drop files here or
Max. file size: 256 MB.

Allergies

Does your 4th child take any medication for allergies?*
Yes
No

Name of Medication:*

Describe recation:*

Is the medication allergy life-threatening?*
Yes
No

Does your 4th child have Bee Sting allergies?*
Yes
No

How do they react to the bee sting?*

Is the Bee stings allergy life-threatening?*
Yes
No

Does your 4th child have any other allgergies?*
Yes
No

What is the reaction to the allergy?*

Is it life-threatening?*
Yes
No

Miscellaneous Screenings and Tests

Please tell us if your child has had any of the screenings listed below and on what date?

Vision*
Yes
No

Date of Vision Screening*

Developmental*
Yes
No

Date of Developmental Screening*
Month
Day
Year

Tuberculosis (PPD)*
Yes
No

Date of Tuberculosis (PPD) Screening*

Sickle Cell Anemia*
Yes
No

Date of Sickle Cell Anemia Screening*
Day
Month
Year

Aptitude*
Yes
No

Date of Aptitude Screening*

Hearing*
Yes
No

Date of Hearing Screening*
Month
Day
Year

Speach*
Yes
No

Date of Speach Screening*

Educational*
Yes
No

Date of Educational Screening*
Month
Day
Year

Has your 4th child had any other type of screening not listed here?*
Yes
No

Other*
Insert the name of the screening and date here.

To the best of my knowledge the information contained above is accurate.
Write you initials in the box on the right.

Parent/Guardian Initial*

Staff Initial __________________________
(Office Use Only)

Date*
Month
Day
Year

4th Child’s Medical Care Provider

4th Child's Primary physician’s name:*

Primary physician’s practice name:*

Phone:*

Physician’s practice address:*
Street Address City State ZIP Code

Preferred hospital/clinic for emergency care:*

City*

State*

Does your 4th child have a Dentist?*
Yes
No

Dentist’s name:*

Dentist’s practice name:*

Dentist Phone*

Dentist’s practice address:*
Street Address City State ZIP Code

4th Child’s Insurance Provider

4th Child’s health insurance provider name:*

Policy number:*

Does your 4th child have a secondary health insurance provider?*
Yes
No

Secondary health insurance provider name:*

Policy number:*

4th Child’s Immunization History

Please check off the STATE REQUIRED immunizations your child has received:*
This a list of immunizations that are REQUIRED by our state.
Diphtheria
Haemophilus Influenza type b (Hib)
Measles
Mumps
Pertussis (Whooping Cough)
Pneumococcal disease
Polio
Rubella
Tetanus
Varicella (Chickenpox)

Please check off the additional immunizations your child has received.*
Anthrax
Hepatitis A
Human Papillomavirus (HPV)
Influenza
Lyme Disease
Meningococcal disease
Rabies
Rotavirus
Shingles (Herpes Zoster)
Smallpox
Tuberculosis
Typhoid Fever
Yellow Fever
COVID 19
NONE LISTED IN THIS SECTION

Signature*
The information provided is accurate.

Upload a copy of your 4th child’s immunization records here:*
Drop files here or
Max. file size: 256 MB.

Additional Medical Policies

1. Prior to enrollment, I must provide the center with updated medical and immunization information for my 4th child. This information is to be kept current and updated in accordance with state childcare regulations

Initial here:*

2. I agree to provide information to the child care center about my 4th child’s conditions, illnesses, allergies or other needs.

Initial here:*

3. If my 4th 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.

Initial here:*

4. If my 4th 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 for pick up as soon as possible and no later than 2 hours after being contacted. If I cannot be reached, the staff will contact those listed in the Child Emergency Contact and Release.

Initial here:*

Emergency Medical Authorization & Consent

In case of a medical emergency, the staff will attempt to contact me, those listed in the Child Emergency Contact and Release, and lastly my physician.

Initial here:*

In case of a medical emergency, I agree that my child may receive first aid and/or CPR.

Initial here:*

In case of a medical emergency, I permit the transportation of my child to a local hospital or another urgent care facility, if necessary, by paramedics or other emergency personnel.

Initial here:*

In case of a medical emergency, I will be responsible for the emergency medical expenses.

Initial here:*

In case of accidental ingestion of a poisonous substance, I consent to my child being treated as directed by the Poison Control Center.

Initial here:*

Product Permission Use & Consent

I give my permission to this center to apply the products I have chosen below to my child.*
Please check which products you will permit.
Sunscreen
Insect Repellant

Initial here:*

I understand that I must supply my own sunscreen and/or insect repellant with a valid expiration date, and it will be labeled with my child’s name.*
Yes - I will provide the sunscreen and/or insect repellant

Initial here:*

I have special instructions for the application process:*
Yes
No

Provide clear and specific application instructions here.*

Parent/Guardian Initial*

Staff Initial __________________________
(Office Use Only)

Date*
Month
Day
Year

Enrollment Agreement

RATE AGREEMENT AND CONTRACT

Hours of Operation

4th Child's Name*

4th Child's Birthdate*
Month
Day
Year

Tiny Toes
For Infants and Toddlers
Hours of operation: 6:30am – 5:00pm

Pre-K CPP Program
Age - 4 year olds
Hours of operation: 6:30am – 5:30pm

Preschool
Ages 2 1/2 - 7 years old
Hours of operation: 6:00am – 5:30pm

School Program
For ages 5 - 12 years
Hours of operation: 6:30am – 5:30pm

Regular operating hours are listed above with the exception of closings for various holidays and inclement weather as described in the Family Handbook. Please consult the current calendar for holidays. There is no reduction in tuition as a result of center closures.

The procedure to notify families should severe weather or other conditions prevent the program from opening on time or at all will be announced on KKTV Channel News. If it becomes necessary to close early, we will contact you or someone listed in the Emergency Contact and Release. It will be your responsibility to arrange for your child’s early pick up.

SCHEDULED ATTENDANCE

The days and hours that I wish to contract for child care are as follows:

If you need the same time all week, complete Monday's field FIRST, the click yes to auto fill the rest of the week.
Yes

Monday - Start Time
Hours
:
Minutes
AM/PM

Monday - End Time
Hours
:
Minutes
AM/PM

Comments:

Tuesday - Start Time
Hours
:
Minutes
AM/PM

Tuesday- End Time
Hours
:
Minutes
AM/PM

Comments:

Wednesday - Start Time
Hours
:
Minutes
AM/PM

Wednesday- End Time
Hours
:
Minutes
AM/PM

Comments:

Thursday - Start Time
Hours
:
Minutes
AM/PM

Thursday- End Time
Hours
:
Minutes
AM/PM

Comments:

Friday - Start Time
Hours
:
Minutes
AM/PM

Friday- End Time
Hours
:
Minutes
AM/PM

Comments:

FEE POLICY

Tuition is not subject to discounts for holidays, emergency closures (i.e., weather), or absence other than hospitalization or absence at the request of a doctor (a written doctor’s note is required to receive credit).

Parent/Guardian Initial*

I agree to pay the full tuition in advance of services rendered.

Parent/Guardian Initial*

I agree to pay the full tuition fee even if my child is absent for one or more days.

Parent/Guardian Initial*

A late fee of $30.00 is due if tuition is not received by 12:00pmTuesday afternoon

Parent/Guardian Initial*

A non-refundable registration fee of $75.00 is due yearly.

Parent/Guardian Initial*

A late pick-up fee of $1 per minute, per child is due if my child is not picked up by scheduled time.

Parent/Guardian Initial*

Accounts not paid by noon on Tuesday of the week will result in immediate termination of service.

Parent/Guardian Initial*

My 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.

Parent/Guardian Initial*

All returned checks or ACH transactions (automatic debits) will be charged a fee up to the maximum amount allowed by law. One returned check or ACH transaction will result in my account being place on “cash only” status.

Parent/Guardian Initial*

A payment ledger for income tax purposes will be provided no later than January 31st.

Parent/Guardian Initial*

FEE POLICY AGREEMENT
This section to be completed by staff; reviewed and initialed by the parent/guardian/sponsor after completion.

STARTING ON ______________________ A FEE OF _________________________ IS DUE
Weekly
Bi-weekly
Monthly

Parent/Guardian Initial

_______________________________

OTHER AGREEMENTS

Private Employment Acknowledgement and Release

Any arrangement/employment between me and staff of this center (i.e., babysitting), outside of the programs and services offered by this center, is an individual endeavor and private matter not connected or sanctioned by this center. This center shall remain harmless from any such arrangement.

Parent/Guardian Initial*

Medical Release

Occasionally, photos will be taken of the children at the center for use within the center or on our website. Please indicate that you authorize the use and reproduction of photographs of your child in conjunction with the program.

Parent/Guardian Initial*

Staff Initial __________________________
(Office Use Only)

Date*
Month
Day
Year

Walking Excursions & Field Trips

I give my permission for my child to participate in supe-rvised walking excursions near and around the center and field trips.

Parent/Guardian Initial*

Handbook Acknowledgement

I understand and agree that it is my responsibility to read and familiarize myself with policies and procedures outlined in the Family Handbook and agree to abide by them.

Parent/Guardian Initial*

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.

Parent/Guardian Initial*

Information contained in the Family Handbook may be subject to change.

Parent/Guardian Initial*

CONTRACT APPROVAL

I certify that I have read, understand, and accept all of the terms and conditions described in this Enrollment Agreement and the Family Handbook.

Parent/Guardian Initial*

Parent/Guardian Signature*
ENTER YOUR FULL SIGNATURE

Date*
Month
Day
Year

____________________________________________
Center Staff Signature
(Office use only)

____________________________________________
Date
(Office use only)