Enrollment Forms

Child Enrollment Form

First Name: Last Name:

Child gender

Male
Female

Date of birth:

Address(Street):

City:

State:

Zip:

Phone number:

City:

Father/Guardian 1 Name:

Cell Phone:

Work Phone:

Address(If different from above) Street:

City:

State:

Zip:

Email Address:

Mother/Guardian 2 name:

Address(If different from above) Street:

City:

State:

Zip:

Email Address:

___________________________________________________

Emergency Contacts

(Child may be released to the following when attempts to reach the parent are not successful)

Primary Contact:

Address(Street,City, Zip, State):

Cell Phone:

Work Phone:

Relationship to child:

Secondary Contact:

Address(Street,City, Zip, State):

Cell Phone:

Work Phone:

Relationship to child:

___________________________________________________

Person's Authorized to Pick Up Child:

Name:
Phone Number:
Name:
Phone Number:
Name:
Phone Number:
Name:
Phone Number:

We must have authorization in advance for anyone other than parent/guardian to pick up child. We will not release child to any person without prior authorization

Please list anyone NOT authorized to pick up your child from Afton View Child Care Center.

(A copy of a court order is required if a biological parent is not allowed to pick up child)

Name:

Name:

___________________________________________________

Medical Information

Medical insurance provider:

Policy #:

Group #:

Physician's Name:

Telephone Number:

Address:

Hospital preferred in case of emergency:

Dentist's Name:

Telephone Number:

Address:

Special conditions, Disabilities, Allergies, or Medical Information for Emergency Situations:

___________________________________________________

Emergency Medical Authorization

As parent/guardian, I give consent for (child’s name) :

Date of birth :

To receive whatever emergency (e.g. first aid, evacuation, disaster) measures are deemed necessary for the care and protection of my child while under the supervision of the center. If medically necessary my child may be transported to the nearest medical facility by the local emergency unit for treatment, if deemed necessary. I understand that I will be responsible for all charges incurred. It is understood that in some medical situations, Afton View Child Care will need to contact the local emergency unit before the parent, child’s physician and/or other emergency contacts on behalf of the parent.

Parent/Guardian Signature:

Date:

Parent/Guardian Signature:

Date:

I agree to review and update this information whenever a change occurs, and at least once a year

Review Date:

Parent/Guardian Signature:

Review Date:

Parent/Guardian Signature:

___________________________________________________

Parent Agreement

Parent/Guardian Name's:

Child's Name:

Date of Birth:

Child's Name:

Date of Birth:

Child's Name:

Date of Birth:

Child's Name:

Date of Birth:

Address:

Telephone Number:

___________________________________________________

Schedule, Payment, And Tuition Agreement

Infants (6wks - 16mos), Toddlers (16mos - 33mos), Preschool (33mos - 1st day of Kindergarten), School age (Kindergarten - 5th Grade)
Monday:

Drop Off Time:

Pick Up Time:

Tuesday:

Drop Off Time:

Pick Up Time:

Wednesday:

Drop Off Time:

Pick Up Time:

Thursday:

Drop Off Time:

Pick Up Time:

Friday:

Drop Off Time:

Pick Up Time:

Infant weekly rate of $422 will apply * Toddler weekly rate of $362 will apply

Preschool weekly rate of $307 will apply * School-age weekly rate of $232 will apply

Tuition will be due on Monday mornings for the current week of care. Full tuition is still due when children are absent, or Afton View Child Care is closed due to holidays or severe weather. Afton View Child Care will be closed New Year’s Day, Martin Luther King Jr. Day, President’s Day, Memorial Day, Independence Day, Labor Day, Thanksgiving Day, the day after Thanksgiving, Christmas Eve and Christmas Day. If holiday falls on Saturday center will be closed on Friday, and if it falls on a Sunday center will be closed on Monday.

Once a family has been enrolled at Afton View Child Care for one year, they will receive one week free of tuition for vacation. This time must be taken in a Monday through Friday sequence. Families must notify center two weeks in advance to use this free week. A two-week notice is also required when withdrawing from Afton View Child Care. If notice is not given to Afton View Child Care, families will be charged two weeks tuition regardless of child’s attendance.

Parent/Guardian will be responsible for all costs incurred to collect on payments not made in a timely manner. These costs may include but are not limited to: fees charged for a collection service, related legal fees or court costs.

This agreement may be terminated by parent/guardian or Afton View Child Care Center with a two-week written notice in advance. Afton View Child Care may immediately terminate this agreement without notice if payments are not made when due, or if there is an issue related to the safety and security of the children or staff in the Center.

Signature of Parent/Guardian:

Date:

Enrollment Forms

Child Enrollment Form

___________________________________________________

Emergency Contacts

(Child may be released to the following when attempts to reach the parent are not successful)

___________________________________________________

Person's Authorized to Pick Up Child:

We must have authorization in advance for anyone other than parent/guardian to pick up child. We will not release child to any person without prior authorization

Please list anyone NOT authorized to pick up your child from Afton View Child Care Center.

___________________________________________________

Medical Information

___________________________________________________

Emergency Medical Authorization

I agree to review and update this information whenever a change occurs, and at least once a year

___________________________________________________

Parent Agreement

___________________________________________________

Schedule, Payment, And Tuition Agreement

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