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    Student Enrollment Form in PDF

    Uploaded by

    Julie Wilburn
    Please check ID of anyone picking up child that is not the parent. Name: Relationship: Address: Phone: Name: Relationship: Address: Phone: Name: Relationship: Address: Phone: Name: Relationship: Address: Phone: Name: Relationship: Address: Phone: I understand that my child will not be released to anyone not listed above. Any other arrangements must be made by calling the center. This form will remain in effect until a new Authorization Release Form is completed. Parent Signature: Date: Witness Signature: Date: Parent

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Student Enrollment Form in PDF

    Uploaded by

    Julie Wilburn
    26 views9 pages
    Please check ID of anyone picking up child that is not the parent. Name: Relationship: Address: Phone: Name: Relationship: Address: Phone: Name: Relationship: Address: Phone: Name: Relationship: Address: Phone: Name: Relationship: Address: Phone: I understand that my child will not be released to anyone not listed above. Any other arrangements must be made by calling the center. This form will remain in effect until a new Authorization Release Form is completed. Parent Signature: Date: Witness Signature: Date: Parent

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    © © All Rights Reserved

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    Please check ID of anyone picking up child that is not the parent. Name: Relationship: Address: Phone: Name: Relationship: Address: Phone: Name: Relationship: Address: Phone: Name: Relationship: Address: Phone: Name: Relationship: Address: Phone: I understand that my child will not be released to anyone not listed above. Any other arrangements must be made by calling the center. This form will remain in effect until a new Authorization Release Form is completed. Parent Signature: Date: Witness Signature: Date: Parent

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    26 views9 pages

    Student Enrollment Form in PDF

    Uploaded by

    Julie Wilburn
    Please check ID of anyone picking up child that is not the parent. Name: Relationship: Address: Phone: Name: Relationship: Address: Phone: Name: Relationship: Address: Phone: Name: Relationship: Address: Phone: Name: Relationship: Address: Phone: I understand that my child will not be released to anyone not listed above. Any other arrangements must be made by calling the center. This form will remain in effect until a new Authorization Release Form is completed. Parent Signature: Date: Witness Signature: Date: Parent

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 9

    Student Enrollment Form

    Child’s Name: Sex: M F


    Birthdate: Birth Place: Ethnicity:
    Child’s Home Address:
    Home Phone:

    1st Parent’s Name:


    Occupation: Employer:
    Work Phone: Cell Phone:
    Email:
    Address: (if different from child)

    2nd Parent’s Name:


    Occupation: Employer:
    Work Phone: Cell Phone:
    Email:
    Address: (if different from child)

    Child lives with: Both Parents Mother Father other:

    Emergency Contact(Other than parents)


    1. Phone #:
    2. Phone #:

    Pediatrician: Preferred Hospital:

    Parent Signature: Date:

    Registration Fee: $75 Cash or Check #


    Office Staff Signature: Date:
    Student Enrollment Form
    Child’s Name:

    2019-2020
    School Year Programs

    Full Day School (9am-3pm) Half Day School (9am - 12:30pm)


    T/TH $80/wk T/TH $225/mo
    M/W/F $110/wk M/W/F $250/mo
    5 Days $165/wk 5 Days $305/mo

    Before Care Program

    8:00 am Drop-Off 7:00 am-8:00 am Drop-Off

    5 Days $40/wk T/TH $30/wk


    M/W/F $35/wk
    5 Days $55/wk

    After Care Program

    4:00 pm Pickup 4:00 pm-5:30 am Pickup

    5 Days $55/wk T/TH $40/wk


    M/W/F $50/wk
    5 Days $70/wk

    Child care hours needed: to


    **Any additional hours must be Pre-approved by Director & Pre-Paid**
    Additional Hours are billed by the hour at a $15/hr. (This fee is not divided in halves or quarters)
    Sibling Discount: 10% Off on Lower cost tuition
     Parent Contract MUST be read and signed by parent(s)/guardian(s) before child begins school
    Personal Data : Family & Social History Form
    Child’s Name: DOB:

    Parent Info
    Legal guardian 1: Mother Father other:
    Name: Age :
    Legal guardian 2: Mother Father other:
    Name: Age:
    Marital Status: Married Living Together Separated Divorced Step-parent
    Custody/Visiting arrangements:

    Brothers & Sisters


    Name: Age: Grade in School:
    Name: Age: Grade in School:
    Name: Age: Grade in School:

    Child Experiences
    Has child had group play experience? Where?
    Does child have playmates?
    What are your child’s favorite indoor/outdoor activities?

    Does your child have fears that you are aware of?

    Development History
    At what age did your child:
    Crawl: Name simple objects: Sit up on own:
    Repeat short sentences: Begin toilet training:
    Sleep through night: Complete toilet training:
    What word does your child use for Urination : Bowel Movement:
    Does child dress self? Y N Undress self? Y N
    Personal Data : Family & Social History Form Cont.
    NAPPING AGREEMENT
    Infants*:I agree to have my child nap in/on a mat, crib, pack & play placed in the infant room.
    Toddlers: I agree to have my child nap in/on a mat or cot placed in the classroom.
    Preschool/Pre-K/UPK : I agree to have my child nap in/on a mat or cot placed in the classroom.

    *Sleeping arrangements for infants require that the infant be placed on his or her back to sleep, unless medical information is
    presented by the parent that shows that this arrangement is inappropriate for that child.

    Sleep Schedule: Regular bed time : to Does your child have interrupted sleep? Y N

    Do you have concerns about your child’s development?


    Speech Fine Motor Gross Motor Behavior Social/emotional
    How would you best describe your child’s personality?

    What are your daycare expectations?

    Please explain any special family traditions or celebrations that you would like to share with us:

    Home Language Questionnaire


    1. What language(s) is spoken in student’s home or residence?
    English Other:
    2. What language(s) are spoken most of the time to the student, in the home or residence?
    English Other:
    3. What language(s) does the student Understand?
    English Other:
    4. What language(s) does the student speak?
    English Other:
    5. In your opinion, how well does the student understand and speak English?
    Very Well Only a Little Not at all
    Understands English
    Speaks English
    Emergency Authorization Form for Medical
    Emergency Treatment

    Child’s Name: DOB

    As parent or legal guardian of , a minor, I hereby give my


    consent to Rosa Venerini ECC or Schenectady UPK to seek medical treatment in the event of an
    emergency. I hereby give my consent to ELLIS HOSPITAL to provide any treatment and conduct any
    tests which are required necessary treatment to the above named minor in my absence.

    Pediatrician Name: Phone:


    Dentist Name: Phone:
    Last Tetanus: Religion:

    In the event of any emergency in which the above named physicians are not available, I give my
    consent to provide treatment by ELLIS HOSPITAL Medical/Dental staff member on duty.

    Other Pertinent Medical Information:

    Insurance Information:
    ID Number: Group Number:
    Subscriber Name:
    Billing Address:
    Parent/Legal Guardian Employer:
    Employer Address:
    Parent/Legal Guardian Phone: Address:

    Signature of Parent/Legal Guardian: Date:


    Health History
    Child’s Name: DOB

    Does your child have a history of:


    High Fevers Ear Infections Colds Chicken Pox Scarlet Fever
    Diabetes Hepatitis Mumps Measles
    Is your child on any medication? Please list medications and dosage:

    Has your child ever been hospitalized? When and for what?

    Has your child had any serious accidents? Describe.

    Allergies
    Does your child have any allergies? Y N Unknown
    List child’s allergies:
    Signs of allergic reaction:
    Asthma Difficulty Breathing Swelling Hay Fever Hives
    Other:
    Do you know what the allergy is caused by?

    Has your child been to the dentist? Y N Dentist:


    Has your child had: Vision Screening: Y N Hearing Screening: Y N
    Is there anything you would like to share about your child’s health?

    Medical Release
    I hereby give consent to the following healthcare agency

    to release medical information on

    (Child’s Name)
    Signature: Date:
    Authorized Release Form
    I, , give the following people permission to pick up my
    child, , from Rosa Venerini ECC. I, & the people listed
    below, understand that if someone other than myself, the parent, pick up my child, he / she will be
    required to present photo identification. The child will not be able to leave the center with an adult who
    1. Is not listed on the registration form as a parent or 2. Is not listed on this authorization form or 3.
    Does not have a photo identification.

    1. Name:
    Relationship:
    Phone:

    2. Name:
    Relationship:
    Phone:

    3. Name:
    Relationship:
    Phone:

    4. Name:
    Relationship:
    Phone:

    Parent Signature: Date:

    I grant permission to Rosa Venerini ECC to use my child’s picture for the following purposes:
    Newspaper Center Website Grant Proposals Displays Video TV Social Media
    -OR-
    I do NOT want my child’s pictures used for anything other than Bloomz

    Parent Signature: Date


    Infant Enrollment Form
    Child’s Name: Sex: M F
    Birthdate: Birth Place: Ethnicity:
    Child’s Home Address:
    Home Phone:

    1st Parent’s Name:


    Occupation: Employer:
    Work Phone: Cell Phone:
    Email:
    Address: (if different from child)

    2nd Parent’s Name:


    Occupation: Employer:
    Work Phone: Cell Phone:
    Email:
    Address: (if different from child)

    Child lives with: Both Parents Mother Father other:

    Emergency Contact(Other than parents)


    1. Phone #:
    2. Phone #:

    Pediatrician: Preferred Hospital:

    Parent Signature: Date:

    Registration Fee: $75 Cash or Check #


    Office Staff Signature: Date:
    Infant Enrollment Form

    Child’s Name:

    2019 – 2020
    Hours: 7:00 am - 5:30 pm

    T/TH $130/wk

    M/W/F $180/wk

    M-F $265/wk

    **As per the OCFS requirement infants are allowed to stay in child care for a maximum of 9 hours

    Child care hours needed: to


    **Any additional hours must be Pre-approved by Director & Pre-Paid**

    Sibling Discount: 10% Off on lower cost tuition

     Parent Contract MUST be read and signed by parent(s)/guardian(s) before child begins the daycare

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