List family members your child lives with. Include first names, relation, and ages of siblings.
Parent/Guardian/Sponsor
Relationship to child
Home Phone
Cell Phone
Home Address (if different from above)
City
State
Zip
Home Email
Work Email
Work Phone
Employer
Work Hours
Work Address
City
State
Zip
Secondary Parent/Guardian/Sponsor
Relationship to child
Home Phone
Cell Phone
Home Address (if different from above)
City
State
Zip
Home Email
Work Email
Work Phone
Employer
Work Hours
Work Address
City
State
Zip
Especially Children Enrollment Application
Enrollment Information Continued
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 personse with whom staf is not familiar provide a photo ID at the time of pick up.]
Person 1 Name
Relationship to Child
Home Phone
Cell Phone
Home Address
City
State
Zip
Home Email
Work Email
Work Phone
Employer
Work Hours
Work Address
City
State
Zip
Person 2 Name
Relationship to Child
Home Phone
Cell Phone
Home Address
City
State
Zip
Home Email
Work Email
Work Phone
Employer
Work Hours
Work Address
City
State
Zip
Parent Initial
Staff Initial
Date
Especially Children Enrollment Application
Medical Information
Child's Name
Birthdate
Weight
Height
Eye Color
Please List/Explain any medical conditions your child has
Please List/Explain any chronic illnesses your child has
Please list a brief history of your child's serious injuries and hospitilizations
Does your child have diabetes? (if yes, please attach care instructions from your physician)
Yes
No
Does your child have asthma? (if yes, please attach care instructions from your physician)
Yes
No
Will medication be asministered regularly? (if yes, please attach care instructions from your physician)
Yes
No
Does your child have any special dietary needs? (if yes, please explain)
Yes
No
Is your child able to participate in all activities? (if no, please explain)
Yes
No
Does your child have any physical restrictions? (if yes, please explain)
Yes
No
Does your child function at the level of other children in his/her age group? (if no, please explain)
Yes
No
Is your child able to walk?
Yes
No
Can you rchild communicate his/her needs?
Yes
No
Does your child need assistance at meal time? (if yes, please explain)
Yes
No
Does your child rest during the day?
Yes
No
Is your child toilet trained?
Yes
No
Does your child use any specail equipment (breathing machine, wheelchair, hearing aid, braces, glasses, etc.)? (if yes, please explain)
Yes
No
Does your child require one-to-one care/supervision on a regular basis for a significant period of time? (if yes, please explain)
Yes
No
Does your child require any accommodations or modification to fully and equally enjoy and participate in a group care setting? (if yes, please explain)
Yes
No
Especially Children Enrollment Application
Medical Information Continued
Allergies
Medication Allergies and Reactions:
Food Allergies and Reactions:
Bee Sting Allergies and Reactions:
Respiratory Allergies and Reactions:
Other Allergies and Reactions:
Are any of these allergies life-threatening? (if yes, please attach care instructions from your physician)
Yes
No
Screenings and Tests
Vision
Developmental
Tuberculosis (PPD)
Hearing
Aptitude
Sickle Cell Anemia
Speech
Educational
Other
To the best of my knowledge the information contained above is accurate
Parent Initial
Staff Initial
Date
Especially Children Enrollment Application
Medical Information Continued
Medical Care Information
Child's Name
Birthdate
Primary Physician's name
Primary Physician's Practice Name
Phone Number
Physician's Practice Address
City
State
Zip
Preferred Hospital/Clinic for Emergency Care
City
State
Dentist's name
Dentist's Practice Name
Phone Number
Dentist's Practice Address
City
State
Zip
Child's Health Insurance Provider
Policy Number
Secondary Health Insurance Provider
Policy Number
Medical Policies
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 child care regulations.
Initial
2. I agree to provide information to the child care center about my child’s conditions, illnesses, allergies or other needs.
Initial
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.
Initial
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.
Initial
Especially Children Enrollment Application
Medical Information Continued
Emergency Medical Authorization and 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
In case of a medical emergency, I agree that my child may receive first aid and/or CPR.
Initial
In case of a medical emergency, I permit the transportation of my child to a local hospital or other urgent care facility, if necessary, by paramedics or other emergency personnel.
Initial
In case of a medical emergency, I will be responsible for the emergency medical expenses.
Initial
In case of an accidental ingestion of a poisonous substance, I consent to my child being treated as directed by the Poison Control Center.
Initial
I give my permission to this center to apply _ to my child. Please check which products you will permit.
Sunscreen
Insect Repellant
Initial
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.
Initial
Please list any special instructions/requests you have for the application process
Parent Initial
Staff Initial
Date
Especially Children Enrollment Application
Rate Agreement and Contract
Child's Name
Birthdate
Regular operating hours are Monday through Friday, 6:30am to 5:30pm except 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 WFF News 4. If it becomes necessary to close early, we will contact you or someone listed in the Emergency Contact and Release, and it will be your responsibility to arrange for your child’s early pick up.
Fee Policy
To be completed by stafff; Reviewed and initialed by the parent/guardian/sponsor after completion
Starting on
a fee of $
is due
Initial
Tuition is due and payable by 5:30 PM every Friday.
Initial
Tuition is not subject to discounts for holidays, emergency closures (i.e., weather or pandemic), or absence other than hospitalization, or absence at the request of a doctor (a written doctor’s note is required to receive credit).
Initial
I agree to pay the full tuition in advance of services rendered.
Initial
I agree to pay the full tuition fee even if my child is absent for one or more days.
Initial
A late fee of $10.00 per day per child is due if tuition is not received on time.
Initial
A non-refundable registration fee of $125.00 is due yearly.
Initial
A late pick-up fee of $5.00 per minute (per child) is due if my child is not picked up before closing.
Initial
Accounts 4 weeks in arrears may result in immediate termination of service.
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.
Initial
All returned ACH transactions (automatic debits) will be charged a fee of $35.00.
Initial
A 2-week written notice is required for any child being withdrawn from the program.
Initial
A receipt for income tax purposes
Will
Will Not
be provided.
Initial
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 to or sanctioned by this center. This center shall remain harmless from any such arrangement.
Initial
Media Release
Occasionally, photos will be taken of the children at the center for use within the center or on our website and/or newsletters. Please indicate that you authorize the use and reproduction of photographs of your child in conjunction with the program.
Initial
Walking Excursions
I give my permission for my child to participate in supervised walking excursions near and around the center.
Initial
Especially Children Enrollment Application
Rate Agreement and Contract Continued
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.
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.
Initial
Information contained in the Family Handbook may be subject to change.
Initial
Contract Approval
I certify that I have read, understand, and accept all of the terms and conditions described in this Enrollment Agreement.