ENROLLMENT FORM 

     Admission Date: ____/____/____		                                     

Child's Name: _______________________________________________________________________
             
Age: __________   DOB ___/___/_____   Sex:  Male [  ] Female [  ]

Child’s Doctor ______________________ Phone: _____________

Address ________________________________________________

Does child have any known health problems?   Yes [  ]  No [  ]
If yes please describe:_______________________________________________________________
  
   ____________________________________________________________________________________
 
Any Allergies ________________________________________________________________________

*Please provide a copy of your child’s current immunization record. 

Father's Name________________________________________________________________________

   Address:  				_____________  	City:  ______________________________          

   Zip Code: ________        Phone:____________________________  Cell:_____________________

   Employer Name_________________________________ Phone:_______________________________

   Work Hours_____________________________

   Mother's Name___________________________________________________________________

   Address:  				_____________  	City:  ______________________________          

   Zip Code: ________        Phone:____________________________  Cell:____________________

Employer Name_________________________________Phone:_______________________________

Work Hours_____________________________

Parent's Marital Status: (circle one) Married     Separated     Divorced     Single     Widowed 

Child Lives With_________________________________

If Divorced, Who Has Legal Custody_________________________

May the Non-Custodial Parent Pickup Child? □ Yes  □ No  

Emergency Contacts Other Than Parents:

Name: ________________________________________ Phone:_______________________ 

Address:____________________________ City:_____________________  Zip:___________
Relationship to child: _____________

Name: ________________________________________ Phone:_______________________ 

Address:____________________________ City:_____________________  Zip:___________
Relationship to child: _____________

My Child(ren) Will Only Released To the People On This Form:
(A valid I.D. is required for non-parent pick up)

Name: ________________________________________ Phone:_______________________ 

Address:____________________________ City:_____________________  Zip:___________

Relationship to child: _____________

Name: ________________________________________ Phone:_______________________ 

Address:____________________________ City:_____________________  Zip:___________

Relationship to child: _____________

	
Media Consent:
I, _________________, do hereby give consent for Sweet Autumn Daycare to photograph & video-tape my child(ren). I understand that these photos may be posted on (daycare) website & used in conjunction with promotion & advertising. I also hereby release any rights to said photos. 
□ Yes  □ No  

____________________________________________________            ______________
Parent Signature                                                      Date     

____________________________________________________            ______________
Parent Signature                                                       Date 

Name of children being enrolled:

1)________________________________________  Date of Birth _______________  

2)________________________________________  Date of Birth _______________ 

3)________________________________________  Date of Birth _______________ 

WEEKLY RATES:                           

Part Time
Ages 2-5                                        $115.00

Full Time
Ages 2-5                                        $125.00                       

Days your child will need care:

Monday   Tuesday    Wednesday    Thursday    Friday

Hours:______ to ______        

Child # as listed above       Weekly Fee      Registration Fee      Total

Child  1                                  __________         __________           __________
Child  2                                  __________         __________           __________
Child  3                                  __________         __________           __________

Based on the information stated above, your TOTAL weekly fee will be:$ _________

Your TOTAL initial startup cost is: $__________ (this includes any one time registration fees)

I agree to pay for all said costs as stated in writing above. I am aware that there is a $5.00 late fee for every day that my payment is late. If I do not make such payments my children will not be able to attend and legal actions may take place.

____________________________________________________            ______________
Parent(s) Printed Name(s)                                            Date

____________________________________________________            ______________
Parent Signature                                                     Date     

____________________________________________________            ______________
Parent Signature                                                     Date 

Policies:                                     

Hours we operate:  Monday thru Friday 7:30am-5:30pm 

Pick up:
There is a $5.00 fee for every 15 minutes that you are late picking up your child. The times for drop off and pick are to be as stated in agreement. Please be courteous and arrive on time. If any one besides the child’s parent will be picking them up then we will need advance notice from the parent. 

Enrollment:
There is a $50 dollar 1 time registration fee to enroll your child. For family’s enrolling more than one child the fee is $50 dollars for the first child and $30 dollars for each child there after.  All forms, required documents, registration fees, and 1st weeks tuition must be received before your child can attend Sweet Autumn Daycare.

Payment:
·    Fees are payable every *FRIDAY the week before care is given in the amount agreed upon in said contract regardless of your child’s absences or **illness. 
     *Unless another pay date has been pre-arranged **Unless free days are being used
·	If payment is not received by Monday morning, then your child will not be able to attend until full payment is received. 
·	Payments will be made in the form of cash, check or money order.

Termination:
You are required to give a 2 week written notice if you decide to terminate your childcare. I will also give a 2 week written notice of termination if I can no longer care for your child. The 2 weeks will be paid in full regardless of whether or not your child is in attendance.  

Illness:
If your child has a fever, diarrhea, cough, and/or any vomiting then he/she will not be able to attend Sweet Autumn Daycare until they have been symptom free for a full 24 hours. If your child does become ill while at daycare then you will be informed to come and get your child ASAP. Please keep in mind the wellness of others as well as the caretakers. Also remember that your child has 5 sick days each year to be used at your discretion. 

Holidays and Closures:  
Closed: Washington’s Birthday, Memorial Day, Independence Day, Labor Day, Thanksgiving (Thursday and Friday) and New Years Day.
These days we will not be open, however your weekly payments will be the same as usual. Enjoy the day off!
Closed: December 24th to 31st. We will be closed for the Christmas holiday with no cost to you.
The provider and parents are also entitled to 1 vacation at 1/2 of your weekly fee. Vacation eligible for this discount will be 10 days (not counting weekends). Notification in advance should be made by both parties of any vacation to be taken so appropriate adjustments can be made to the account. 

Father’s Signature
	Date	
Mother’s Signature
	Date	
Provider Name
	Date	
                                             
 Emergency Consent

If I cannot be reached to make arrangements for emergency medical care for my child at the time of an illness, accident, or injury, I give my permission for: Beth & Desiree Trevino to obtain whatever treatment may be deemed necessary for: 

_________________________________________ 			_______________________ 
	Name of Child #1						       (D.O.B) 

_________________________________________ 		 	_______________________ 
	Name of Child #2						       (D.O.B) 

_________________________________________ 		 	_______________________ 
	Name of Child #3						       (D.O.B) 

Emergency Parental Consent
When there is a medical emergency, or when a child needs immediate medical treatment, Beth & Desiree Trevino, of Sweet Autumn Daycare will take all reasonable steps to see that the children in their care receive adequate medical care. When appropriate, 911 and then the parent(s) will be called. If the parent(s) cannot be reached we will proceed to call the person(s) listed below who are authorized by the parent to give permission for the medical treatment of the child.

Name: _____________________________________ 	Phone: _____________________

Name: ____________________________________   	Phone: _____________________

If the parent(s) and the authorized person(s) cannot be reached, we will call the child’s doctor, identified below. If the child must be taken to a hospital, we will take the child to the child’s hospital identified below.  If, under the circumstances, it is more reasonable to bring the child to another hospital, they have permission to do so. In the situation where the parent(s) and the person(s) authorized to give permission for medical treatment cannot be reached, the parent authorizes the child’s doctor to provide the appropriate medical treatment for the child.
Name of Doctor:	Phone Number:
	
Address:
	
Name of Dentist:
	Phone Number	
Address:
	
Name of Hospital/Clinic:	Phone Number:
	
Address:

This form is legally binding, so by signing it, you agree that all of the information provided herein is correct.  False Information may result in termination of childcare services, forfeiture of childcare retainer, or both.

Father/Guardian’s Signature:
	Date:	
Mother/Guardian’s Signature:	Date:
	
Provider Signature
	Date:	
Child’s Name: ________________________________________
Does your child have a nickname? □ Yes	 □ No  
If yes, what is it:____________________________

Name of School: _______________________________________________
Address: _______________________________   Phone: ______________
School hours: __________________________________________________
How will you child get to and from school: ____________________________

Family   								 
Names of brothers & sisters		               Age	
________________________________	      _____________
________________________________	      _____________
________________________________	      _____________

Food
Describe your child’s appetite: ______________________________________________
______________________________________________________________________

What foods does your child dislike? __________________________________________
______________________________________________________________________

What foods does your child like? ____________________________________________
______________________________________________________________________

Does your child feed him/herself?  □ Yes   □ No    
Does your child have any food sensitivities?  □ Yes   □ No

If yes, please identify: ____________________________________________________
______________________________________________________________________

Will your child be taking a lunch to school? □ Yes  □ No

Self-Care
Is your child in diapers? □ Yes   □ No	Comment: ______________
Has training begun? 	 □ Yes   □ No	Comment: ______________
Is your child trained?  	 □ Yes   □ No	Comment: ______________
Does your child need any help with dressing?  □ Yes   □ No
If yes, please list: ______________________________________________________

Sleep
Describe your child’s sleep routine (include naps & lengths of naps): ______________________________________________________________________
______________________________________________________________________                                                                                                                                                                           

Social/Emotional Development
Does your child separate easily from you? □ Yes  □ No

Please comment: ________________________________________________________

Is your child afraid of anything? □ Yes  □ No
Please comment: ________________________________________________________

Does your child have a favorite toy, blanket or soother? □ Yes  □ No
Please identify: __________________________________________________________
Does your child spend time with other children? □ Yes  □ No
Please comment: ________________________________________________________

How does your child show feelings?
Affection:_____________________     Fear:_____________________
Frustration:___________________     Anger:____________________
Excitement:___________________

What activities does your child enjoy? ________________________________________
______________________________________________________________________

What activities does your child dislike? _______________________________________
______________________________________________________________________

How do you handle discipline in your home? ___________________________________
______________________________________________________________________

What characteristics in your child’s development would you like:
Encouraged?____________________________________________________________
______________________________________________________________________

Discouraged?____________________________________________________________
______________________________________________________________________

Please provide any other information relating to your child that would be helpful in understanding and caring for your child: ______________________________________
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________