Child Enrollment Packet

R’Club Enrollment Packet

Enrollment Packet Instructions

PLEASE READ THESE DIRECTIONS BEFORE COMPLETING ENROLLMENT FORMS

• Enrollment forms are in PDF format and require Adobe Reader. If you do not have Adobe Reader, it can be downloaded for free. Paper copies of enrollment forms and other required documents can be obtained at every R’Club Child Care location.

• The forms can be filled in on your computer, saved and printed, or you can print the forms and fill them in by hand. Save your work frequently.

• If you are enrolling more than one child, you can save a second copy by renaming the file and changing only the information on the next child.

• All enrollment forms must be turned in at your child’s R’Club site or center and must be signed and dated by you.

• You must fill out at the center two emergency treatment forms and an emergency tag for your child. These forms will be signed and notarized on site at registration.

• You will need to bring with you: the date of your child’s last DPT or tetanus shot, and your health insurance company information.

• Completed forms can be turned in at the R’Club program your child will be attending. Enrollment is not confirmed until the registration and first weeks fees are paid.

IMPORTANT SPECIAL INSTRUCTIONS: All spaces on the Child’s Enrollment Record form must be filled in completely. Enter NONE or NA if the item does not apply.

Checklist for Children's Files

Enrollment Record (2 pages)

Child Information Sheet (2 pages)

2 Notarized Emergency Treatment Form (Cards)

Disaster Card

Fee Policy Agreement

Calendar

Discipline Policy

Administration Medication Policy (if applicable)

Subsidy Application (if applicable)

Cross Reference (list siblings, if applicable)

JWB Written Statement of Purpose for Collection of Social Security Number

JWB Authorization and Consent for Disclosure, Receipt, and Use of Confidential Information

Parent Handbook

Know Your Child’s Day Care Brochure & Influenza Virus Brochure

Alternate Nutrition Agreement

Food Experience Form

Child's Enrollment Record

Site Name

Child's full legal name

Date of Birth Sex

Primary Hours of Care From To Days of Week in Care

Child’s Physical Address

Family Information

Child Lives with

Custody: Mother Father Both Other

Emergency Contacts

Child will be released only to the custodial parent or legal guardian and the persons listed below.

Child's Enrollment Record Page 2

Child's Physician/Health Resource

Telephone Number

Address

Hospital Preference

Name of Dentist Telephone

Address

Emergency Care Plan instructions (if applicable)

Miscellaneous Information

List all known allergies

List all identifying scars, birthmarks, skin discolorations

Special medical or dietary needs of child

List any areas of concern

Signature

Child Information Sheet

Child’s Name Site Name Page

Health Information

1. Please indicate (Yes or No) if your child needs assistance/accommodations in any of the following areas. If yes, please explain.

Visual: Yes No

Hearing: Yes No

Physical: Yes No

Speech: Yes No

Other: Yes No

2. Does your child have other special needs (physical, emotional, mental)? Yes No

3. Does your child have seizures? Yes No

4. Has your child had (check boxes): Surgery Serious Illness Burns Accidents Other

5. Does your child have an I.E.P. or 504 plan with the school system? Yes No

6. Is your child currently taking medication? Yes No

Development / Assets

8. Does your child have dressing skills? Yes No

Feeding skills? Yes No

Toileting skills? Yes No

9. Can your child participate in all activities? Yes No

10. List any particular sources of frustration for your child

11. List any behavioral concerns and how these are addressed at home/school

Statistical Information

1. Race: Black or African American Asian or Asian Indian Native Hawaiian/Other Pacific Islander White Multi-racial Native American or Alaskan Indian

2. Ethnicity: Hispanic or Latino Not Hispanic or Latino

3. New to R'Club or returning? New Returning

4. How long or how many years has your child attended R'Club programs?

5. Family Size: adults children under age 18 children over age 18

6. Total Annual Household Income

7. How did you hear about R’Club?

8. Did you use the Yellow Pages phone book to find R'Club? Yes No

9. Why did you choose R’Club? Convenience or location Price Curriculum or academic support Activities offered Safety and supervision Reputation Previously had children enrolled Other

10. Please list all children in family attending any R’Club or preschool centers

11. Mother/Guardian Primary E-Mail

12. Father/Guardian Primary E-Mail

R'Club Use Only

Enrollment School Age Code

Fundar Amt Parent Fee Total Fee

Activity Fees Check Box

Fee Policy Agreement

Center / School Name Child’s Name Parent’s Name

I have read, understand and agree to abide by all the policies listed above. Fees for the services will be:

Discipline / Expulsion Policy

I have read, understand, and agree to comply with the R’Club Discipline Policy. Date

JWB Written Statement of Purpose for Collection of Social Security Number

Parent/Guardian or Participant acknowledgements and signatures:

JWB Authorization and Consent for Disclosure

Participant authorization entries:

Witness Signature Date

Promise Time Statement of Commitment

I understand the activities of the Promise Time program include:

• Youth will complete pre, mid and post-assessments.

• Youth will participate in tutoring, enrichment and online activities.

• Youth will participate in project-based learning activities.

Print parent/guardian name

Print youth name

Director Signature Date

Parental Authorization to Release Form

Promise Time Extended Learning

Child

Beginning on

Days From p.m. To p.m.

Parent Signature Date

R’Club Program Intake Form

Center Name

Child Name

Date of Birth Gender M F Age of Child

Home Address City Zip Code

School Name Current Grade Level IEP Yes No

Pinellas County Student ID

Lunch Eligibility: Free Reduced Not Eligible

Annual Household Income $

Parent/Guardian Signature Date

Consent and Authorization for Disclosure

Print Participant Name

Print Name of Parent/Guardian

Signature of Parent/Guardian Date

Witness Signature

Food Experience Permission Form

Child’s Name

My child DOES NOT have a food allergy or dietary restriction.

My child DOES have a food allergy or dietary restriction. He or she may participate, but may not eat or handle the following items:

My child DOES have a food allergy or dietary restriction. He or she may not participate in activities.

Parent Signature Date

Donation Selection

Please SELECT the correct option, sign and complete the bottom of this form as confirmation to your commitment to this donation.

I wish to make a $ donation weekly above and beyond my weekly fees.

I wish to make a one-time donation of $ .

I do not wish to commit to an added donation at this time.

I wish to end my elected donation as of this date

Parent/Guardian Name

Signature Date

Center Name

Director Name

Director Signature Date

Sign Now