Student ELC Registration

STUDENT ELC REGISTRATION

Student Information

Student Full Legal Name:

Date of Birth:    Student ID:

Infant (6 weeks–12 months)    Toddler (13–35 months)    Preschool (3–4 years)    Pre-K (4–5 years)

Preferred Start Date:    Requested Schedule:

Full-time    Part-time    Drop-in

Mon   Tue   Wed   Thu   Fri   Sat   Sun

Parent / Guardian Information

Emergency & Authorized Pickup

Medical Information & Immunizations

Immunizations up to date: Yes No

Tuition, Fees & Payment

Agreed Tuition Amount per month:

Weekly   Bi-weekly   Monthly

Bank draft (ACH)   Credit card   Check

Late Payment Fee: A late fee of 1.5% per month (or the maximum permitted by law) will be charged on overdue balances. Returned payment fees apply. Tuition is billed according to selected frequency and is due when invoiced.

Authorizations, Consents & Policies

Emergency Medical Authorization: In the event of an emergency where immediate medical treatment is required and the parent/guardian cannot be reached, I authorize the program staff to obtain emergency medical services for my child. I understand that I am responsible for all costs associated with emergency care and agree to hold the program harmless for actions taken in good faith.

Illness & Exclusion Policy: I agree to follow the program's health exclusion policy and will not bring my child if contagious illness or fever is present. The program reserves the right to exclude any child who exhibits symptoms that pose a health risk to others.

Medication Administration: I authorize program staff to administer medication to my child as directed in writing. All medications must be provided in original labeled containers with written dosing instructions.

Photo/Media Release: I consent to the use of my child's image for program educational and promotional materials. I do not consent.

Field Trip & Transportation Authorization: I authorize my child to participate in supervised field trips and transportation arranged by the program.

Release & Indemnity: By enrolling my child, I release the program, its employees and agents from liability for injury or loss except that arising from willful misconduct or gross negligence. I agree to indemnify the program for claims arising from my child's actions while in attendance.

Termination & Withdrawal: The program may terminate enrollment for failure to comply with policies, nonpayment, or behavior issues that jeopardize safety. Withdrawal by the parent/guardian requires written notice; tuition responsibility continues through the notice period as set by program policy.

I acknowledge receipt of and agreement to the ELC Parent Handbook and policies.

I agree to the tuition, payment, and refund policies described above.

I authorize emergency medical treatment as described in this form.

I authorize program staff to administer medication in accordance with written instructions.

Additional Instructions / Notes

Certification

By signing below, I certify that the information provided on this registration form is true and accurate to the best of my knowledge. I understand that falsification of medical or emergency contact information may jeopardize care and may result in termination of enrollment. I authorize the program to contact the emergency contacts and health care providers listed above if necessary.

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