Infant Enrollment Form

INFANT ENROLLMENT FORM

Child Information

Child Full Name:

Preferred Name:     Date of Birth:

Gender:     Student ID (if assigned):

Enrollment & Program

Payment Plan:     First Payment Due:

Parent / Guardian Information

Emergency Contacts & Authorized Pickup

Emergency Contact 1:    Phone:

Emergency Contact 2:    Phone:

Medical & Health Information

Immunizations up to date:     Immunization exemption claimed:

Feeding, Sleeping & Diapering

Permissions & Consents

I authorize staff to administer over-the-counter medications (e.g., infant acetaminophen) as needed per center policy:

I authorize staff to apply diaper cream, sunscreen, and barrier ointments as instructed:

I consent to the use of diapers and disposable supplies provided by the center if my supplies run out:

I grant permission for my child to be photographed or videotaped for educational or promotional materials:

I authorize emergency transportation and medical treatment if necessary:

Policies, Fees & Acknowledgments

Enrollment Agreement: By signing below I agree to enroll the child named above and to pay all tuition and fees in accordance with the schedule set by the center. Tuition is due on the dates indicated on the center's billing statement; late payments are subject to late fees and possible suspension of services. Fees paid in advance are not refundable except as described in the center's fee policy.

Health & Exclusion Policy: I understand the center's obligation to exclude children with communicable illnesses and to require clearance from a physician for readmission when warranted. I agree to immediately remove my child from care if requested for health reasons.

Medication Administration: Prescription medications will only be administered with a completed medication authorization form, original pharmacy labeling, and precise dosing instructions. I release the center and its employees from liability for administration of medication in accordance with these instructions, provided staff act in good faith and follow center policy.

Emergency Treatment Authorization: In the event of an emergency, if I cannot be reached, I authorize the center to obtain emergency medical treatment for my child and, if necessary, to transport my child to an appropriate medical facility. I agree to be financially responsible for any costs incurred as a result of emergency care.

Release of Liability: To the fullest extent permitted by law, I release, indemnify, and hold harmless the center, its employees, and agents from claims arising out of ordinary negligence in connection with my child's participation in center activities, except for willful or intentional misconduct.

Termination: The center reserves the right to discontinue enrollment for nonpayment, failure to comply with health and safety policies, or behavior that endangers the health or safety of children or staff. Families will be given written notice when practicable.

Emergency & Special Instructions

Parent/Guardian Certifications

I certify that the information provided on this form is true and complete to the best of my knowledge. I agree to notify the center immediately of any changes in the information provided. I have received, read, and agree to comply with the center's written policies, including those concerning health, safety, discipline, and tuition. I authorize the center to contact the health care provider or other listed contacts as necessary to support my child's health and well-being.

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