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
(optional)
Example: The child listed above lives with her mother and her father. The child has no siblings. She has one pet cat.
EMERGENCY CONTACT #3
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)
If they have none, write N/A
Staff Initial __________________________ (Office Use Only)
The information provided is accurate.
1. Prior to enrollment, I must provide the center with updated medical and immunization information for my 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 child’s conditions, illnesses, allergies or other needs.
3. 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.
4. 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 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.
Staff Initial __________________________ (Office Use Only)