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
Which Life Centered Program are you enrolling your 4th child in?* 4th Child Full Legal Name* Full Name
4th Child’s nickname: Nickname
4th Child's Birthdate:* 4th Child’s home address:* Upload a photo of your 4th child here: (optional)
Does your 4th child attend school?* 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.
Does the parent/guardian/sponsor live in the same home as the 4th child? What is the Paret/Guardian/Sponor's home address?* Is the Parent/Guardian/Sponsor of the 4th child currently employed? Employer address:* Home address:* Emergency Contact #1's home address
Is emergency contact person #1 employed?* Address Would you like to list a #2 emergency contact person?* Address Is emergency contact person #2 employed?* Address* Would you like to list a #3 emergency contact person?* EMERGENCY CONTACT #3
Address* Is emergency contact person #3 employed? Employer address:* 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.
Staff Initial __________________________ (Office Use Only)
Date* 4th Child' Birth date:* 1. Does your 4th child have any special medical conditions?* Explain special medical conditions:*
2. Does your 4th child have any chronic illnesses?* 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?* 5. Does your 4th child have asthma?* 6. Will medication be administered regularly?* If you answered yes to any of the medical conditions listed above, please upload care instructions from your physician here.*
7. Does your 4th child have any special dietary needs?* 8. Is your 4th child able to fully participate in all activities?* Explain why your 4th child CAN NOT fully participate in all activities.*
9. Does your 4th child have any physical restrictions?* Eplain what 4th child's physical restrictions:*
10. Does your 4th child function at the level of other children in his/her age group?* 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?* 12. Can your 4th child communicate his/her needs?* 13. Does your 4th child need assistance at meal time* Eplain what assistance your 4th child needs at mealtime:*
14. Does your 4th child rest during the day?* 15. Is your 4th child toilet trained?* 16. Does your 4th child use any special equipment, such as breathing machine, wheelchair, hearing aid, braces, glasses etc?* 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?* 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?* Eplain how your 4th child requires accommodations or modifications to fully and equally enjoy and participated in a group care settings:*
Please check all that apply (Illness history)* Please upload care instructions from your physician for any of the illnesses listed above..*
Please check all that apply (Disease History)* If you selected any of the illlnesses above, please upload care instructionss from your physician.*
Does your 4th child take any medication for allergies?* Is the medication allergy life-threatening?* Does your 4th child have Bee Sting allergies?* How do they react to the bee sting?*
Is the Bee stings allergy life-threatening?* Does your 4th child have any other allgergies?* What is the reaction to the allergy?*
Is it life-threatening?* Vision* Date of Vision Screening* Developmental* Date of Developmental Screening* Tuberculosis (PPD)* Date of Tuberculosis (PPD) Screening* Sickle Cell Anemia* Date of Sickle Cell Anemia Screening* Aptitude* Date of Aptitude Screening* Hearing* Date of Hearing Screening* Speach* Date of Speach Screening* Educational* Date of Educational Screening* Has your 4th child had any other type of screening not listed here?* Staff Initial __________________________ (Office Use Only)
Date* Physician’s practice address:* Does your 4th child have a Dentist?* Dentist’s practice address:* Does your 4th child have a secondary health insurance provider?* Please check off the STATE REQUIRED immunizations your child has received:* This a list of immunizations that are REQUIRED by our state.
Please check off the additional immunizations your child has received.* Signature* The information provided is accurate.
Upload a copy of your 4th child’s immunization records here:*
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
2. I agree to provide information to the child care center about my 4th child’s conditions, illnesses, allergies or other needs.
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.
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.
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.
In case of a medical emergency, I agree that my child may receive first aid and/or CPR.
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.
In case of a medical emergency, I will be responsible for the emergency medical expenses.
In case of accidental ingestion of a poisonous substance, I consent to my child being treated as directed by the Poison Control Center.
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.
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.*
I have special instructions for the application process:* Staff Initial __________________________ (Office Use Only)
Date*