Childcare Enrollment Document

CHILDCARE ENROLLMENT DOCUMENT

Child Information

Child Full Legal Name:

Requested Start Date:

Parent / Guardian Information

Emergency Contacts / Authorized Pickups

Emergency Contact 1 - Name: Phone:

Emergency Contact 2 - Name: Phone:

Attendance Schedule

Intended Days of Attendance: Monday Tuesday Wednesday Thursday Friday

Health, Medical & Immunizations

Immunization Status: Up to date Partially complete (explain below) Exempt / waived

Permissions, Consents and Legal Acknowledgements

I hereby authorize the childcare facility and its employees and agents to provide routine care, administer medication as prescribed in writing by a licensed prescriber, and seek emergency medical treatment for my child if I cannot be reached. In the event of an emergency, I authorize transportation to the nearest medical facility and any necessary treatment. I agree that the facility may disclose necessary health information to medical personnel and emergency responders as required for care.

Permission for Administration of Non-Prescription Topical Products (e.g., sunscreen, diaper ointment): Yes No

Permission to Transport Child for Supervised Local Activities and Short Field Trips: Yes No

Permission to Use Photographs or Video that May Include My Child for Educational or Promotional Materials (no full names published): Yes No

Release and Indemnification: In consideration of childcare services, I release and hold harmless the facility, its employees, agents, and volunteers from claims arising out of ordinary negligence in providing care, except for willful misconduct or gross negligence. I agree to indemnify the facility for claims arising from my child's actions that cause injury or property damage.

Tuition, Fees and Payment Terms

Late Payment Fees and Returned Payment: Late payments are subject to a late fee as set by the facility and may result in suspension of services. Returned payments incur a returned payment fee and all subsequent payments must be made by certified funds if requested.

Withdrawal and Refunds: To withdraw from services, written notice of withdrawal is required at least 14 calendar days prior to the next billing cycle unless a different notice period is separately agreed. Deposits and registration fees are non-refundable except where required by law or explicit written agreement.

Policies, Attendance & Termination

Health Exclusion Policy: Children with contagious illness, fever, vomiting, or other symptoms that prevent participation in regular activities must remain at home until cleared by a health professional or symptom-free for 24 hours as required by facility policy. The facility reserves the right to require a physician's clearance for readmission.

Behavior Management: The facility maintains behavior management policies to promote a safe environment. Persistent behavior that threatens the safety of the child or others may result in suspension or termination of services following reasonable efforts to address concerns.

Termination by Facility: The facility may terminate this agreement for nonpayment, repeated late pickup, failure to comply with required health or registration documentation, or for other material breaches after providing written notice and an opportunity to cure where practicable.

Privacy and Records

The facility maintains records related to care and will release information when required by law or to protect the health and safety of the child. Parents may request access to their child's records in accordance with facility procedures.

Acknowledgment & Certification

By signing below, I certify that I am the parent or legal guardian of the child named above, that the information provided in this enrollment document is true and complete to the best of my knowledge, and that I have read, understood, and agree to comply with the policies, consents, and terms set forth in this document. I authorize the facility to contact the persons listed for emergency care and to act in my stead in accordance with the permissions granted herein.

I understand that failure to provide required health or emergency information may result in delayed care or inability to attend until documentation is provided. I agree to update the facility promptly of any changes to the information provided.

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