The Salvation Army Child Development Center Application for Enrollment

Date Enrolled: ______________

Student Information Full Name: _____________________________________________________________________ Last

First

Middle

Nickname

Child’s Physical Address: ___________________________________________________________ Street

Date of Birth: _______________

City

Sex: _________

Zip Code

Primary Hours of Care: ________ to _________

Name of Person Enrolling Student: __________________________

Relationship: _______________

Family Information Child Lives With: ______________

Custody: Mother _____ Father _____ Both _____ Other _____

Mother’s Name: __________________________

Father’s Name: __________________________

Address: _______________________________

Address: ______________________________

Home Phone: ____________C ell: ____________

Home Phone: ____________C ell: ___________

Employer: ______________________________

Employer: _____________________________

Address: _________________Ph: ___________

Address: _________________Ph: ___________

Email: _________________________________

Email: ________________________________

Medical Information I hereby grant permission for the staff of The Salvation Army Child Development Center to contact the following medical personnel to obtain emergency medical care if warranted. Doctor: ______________________

Address: _____________________

Phone: _____________

Dentist: ______________________ Address: _____________________

Phone: _____________

Hospital Preference: ______________________________________________________________ Please list any allergies, special medical or dietary needs, or other areas of concern: ____________________ ____________________________________________________________________________

Contacts The child will be released only to the custodial parent or legal guardian and the persons listed below. The following people will also be contacted and are authorized to remove the child from the facility in case of illness, accident or emergency, if for some reason the custodial parent or legal guardian cannot be reached. ____________________________________________________________________________ Name Relationship Home Phone Cell Phone Work Phone ____________________________________________________________________________ Name Relationship Home Phone Cell Phone Work Phone ____________________________________________________________________________ Name Relationship Home Phone Cell Phone Work Phone

The Salvation Army Child Development Center Application for Enrollment

Student Name: ______________

Helpful Information About Child _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________

DCF Requirements Section 65C-22.006(2), F.A.C., requires a current physical examination (Form 3040) and immunization record (Form 680 or 681) within 30 days of enrollment. The Salvation Army Child Development Center requires both the physical form and the immunization record upon enrollment. A student may begin care the day after both forms are received. Section 402.3125(5), F.S., require that parents receive a copy of the Child Care Facility Brochure “Know Your Child Care Facility” (CF/PI 175-24), or Section 65C-20.11 (2)(c)(1), F.A.C., requires that parents receive a copy of the Family Day Care Home Brochure “Selecting A Family Day Care Home Provider” (CF/PI 175-28). A copy of “Know Your Child Care Facility” is distributed with our Parent Handbook upon enrollment. Section 65C-22.006(3)(c)2., F.A.C., requires that parents are notified in writing of the disciplinary practices used by the child care facility, or Section 65C-20.010(6)(c), F.A.C., requires that a written copy of the day care provider’s discipline policy be available for review by the parent(s). Our Parent Handbook explains the disciplinary practices used by The Salvation Army Child Development Center (page 16). Parents will receive a copy of this information upon enrollment. Your signature below indicates that you have received the above items and that all information on this enrollment form is complete and accurate. _________________________________________ Signature of Parent/Guardian

___________________________ Date

Parent Handbook Agreement Incompliance with the policies and procedures described within the Parent Handbook, I fully understand and agree to comply with all responsibilities and expectations during my child’s enrollment. I also hereby acknowledge that I have received a copy of the Parent Handbook. _________________________________________ Signature of Parent/Guardian

___________________________ Date

The Salvation Army Child Development Center Application for Enrollment

Student Name: ______________ Media Release

I, the undersigned, do hereby give my consent for my child to be photographed or videotaped, while in the care of The Salvation Army Child Development Center. I understand that these photographs and/or videos will only be used as displays within the center, for advertising purposes, and/or for public relations purposes (i.e. Facebook). I further understand that I may revoke this consent at any time upon notifying the center director. _________________________________________

___________________________

Signature of Parent/Guardian

Date

Field Trip Consent My child, _________________________, has my permission to participate in any field trips planned by the staff of The Salvation Army Child Development Center. I understand that individual seat belts or child restraint seats will be used for each child and adequate supervision will be provided during the trip. I do hereby release and discharge The Salvation Army, its agents, employees and officers from all claims, demands, actions, judgments and executions which the undersigned’s heirs, executors, administrators and assigns may have or claim to have against its successors or assigns to all personal injuries known or unknown caused by or arising out of any planned field trip. _________________________________________

___________________________

Signature of Parent/Guardian

Date Christian Consent

I understand that my child is enrolled in a Christian learning center. I further understand that children ages 3, 4 and 5 will at times have the opportunity to attend a child’s chapel service. _________________________________________ Signature of Parent/Guardian

___________________________ Date

Participation Consent I give permission for my child, ___________________________, to participate in cooking activities, birthday parties and other classroom events where food that is not on the menu will be present. _________________________________________ Signature of Parent/Guardian

___________________________ Date

Statement Preference Statements are generated at the beginning of each week and distributed to each family either as a paper or electronic copy. Please indicate your preferred delivery method. _____ Paper Copy

_____ Electronic Copy (Best email address:_____________________________ )

The Salvation Army Child Development Center Application for Enrollment

Student Name: ______________

Tuition Agreement Tuition and fees are billed at the beginning of each week based on the CDC’s current fee schedule. Any monies due will be specified on the family’s statement. Payments must be received by Wednesday at the close of business. If your account has any balance after this deadline, a fee of $5.00/student will be charged. Any balance at the end of the week must be paid before your student(s) can be readmitted the following Monday. Payments for multiple weeks is allowed, but must be paid in advance to not receive late payment charges. Cash payments will be accepted Monday-Friday until 10:30 a.m. to the office staff. Checks and Money Orders can be placed in the locked box in the lobby. There will be a $25 fee for all returned checks. I agree to the above terms and conditions, including the obligation to pay to the Child Development Center all charges for tuition and fees, and in all events to be responsible for the financial obligations of my child. _____________________________

__________________________

_______________

Signature of Parent/Guardian

Print Name

Date

Parent Orientation Plan Selecting a child care facility is a significant decision for families. It is very important that parents are oriented to the child care program where their child will be receiving services. Knowing and understanding the policies and procedures of the child care program can have a positive impact on families and their child care experience. This is your orientation checklist. We will be sharing information with you about the Child Development Center and also providing you with a copy of the Parent Handbook which contains our policies and procedures. This orientation is intended to help you understand what you need to know as you leave your child in our care. We plan to cover all areas listed below with you. If an area is not covered, or if you do not receive a copy of the Parent Handbook, please be sure to let us know.

□ □ □ □ □ □ □

Tour of center Introduction to teachers/staff Classroom visits (transitional ease) Overview of Parent Handbook Regular communication with parents Daily information to be shared with parents Parent resources in lobby

□ □ □ □ □ □ □

Parent and center expectations Items to be provided by parents / provider Meals and nutrition Daily activities Payments for child care services Late pick-up fees Late payment fees

My signature below indicates that I have received a copy of the center’s policies and procedures and an orientation was conducted with me which covered all areas outlined in this orientation plan. _________________________________________ Signature of Parent/Guardian

___________________________ Date

The Salvation Army Child Development Center Application for Enrollment

Student Name: ______________

Child Health and Development Questionnaire Child’s Full Name: ____________________ Date of Birth: ______________ Race: _______ Sex: ____ Today’s Date: _________________ Please answer the questions on this form, as this information will help us be more effective in working with your child. Thank you!

1.

Please indicate if your child has had any of the following childhood diseases: ____ Chicken Pox Date ________________ ____ Measles ___ 3 day (Rubella) Date ________________ ___ 10 day (Rubella) Date ________________ ____ Scarlet Fever Date ________________ ____ Mumps Date ________________ ____ Strep Throat Date ________________

2. Is your child taking over-the-counter or prescribed medication regularly at home? ____ No ____ Yes If Yes, please describe: ___________________________________________________________ 3. Is your child taking vitamins regularly at home? ____ No ____ Yes 4. List any known food or environmental allergies. _________________________________________ 5.

Does your child complain of being ill often? ____________________________________________

6. Has your child ever had a seizure or have you suspected him/her of having a seizure? ____ No ____ Yes 7.

Describe your child’s appetite. _____________________________________________________

8. Does your child dislike any foods? ____ Yes If so, what? ___________________________________ 9. What does your child usually eat for breakfast before arriving at school? _________________________ 10. How easily does your child fall asleep? ________________________________________________ What is the usual bedtime? _________________ Wake up time? __________________ What is the usual naptime? _________________ Wake up time? __________________ 11. Is your child completely toilet-trained? ____ No ____ Yes 12. Does your child remain dry all night? ____ No ____ Yes 13. At what age did you child begin to walk alone? __________________________________________ 14. Are other adults (non-family) able to understand the child’s speech? ___________________________ 15. What is your child’s favorite toy or activity at home? ______________________________________ 16. Does your child have temper tantrums? ____ No ____ Yes If Yes, how do you deal with them? _______ __________________________________________________________________________ 17. If you could describe you child in one word, what would it be? _______________________________ 18. Please list your child’s strong points (happy, curious, loving, etc.) _____________________________ 19. Is there anything else, medical or otherwise, that we should know about your child? ________________ _________________________________________________________________________ (To be completed by parent or guardian)

The Salvation Army Child Development Center Application for Enrollment

Student Name: ______________

Alternate Nutrition Agreement If food or formula is to be supplied by the child’s parents, there shall be a written agreement on file at the center with a copy given to the parent. This form shall define the responsibilities of the parent and the center in meeting the child’s nutritional needs and shall be signed by the parent and the operator of the day care. Young children are growing and the foods they eat are the materials their bodies use to grow. The food a child eats affects his/her growth, energy, attitudes, intelligence and general health. Name of Child __________________________________________________________________ Please indicate food allergies or special problems __________________________________________ ____________________________________________________________________________ I agree to provide the following meals and/or snacks to meet the child’s daily nutritional needs: (Mark P for Parent Provides or C for Caregiver Provides)

Breakfast

AM Snack

Lunch

PM Snack

Dinner

I agree to discuss any questions which might develop in the use of the Alternate Nutrition Agreement. _________________________________________ Signature of Parent/Guardian

___________________________ Date

_________________________________________ Signature of Caregiver

___________________________ Date

Modified Diet Arrangements shall be made between the provider and parent for a child’s modified diet when prescribed by a physician. The physician’s order, a copy of the diet and sample meal plan for the modified diet shall be in the child’s record. If a child cannot follow the meal pattern requirements, the following must be on file in the day care facility. Child’s Name: ________________________________

Date of Birth: _______________________

This child should be served _________________________________________________________ Instead of _____________________________________________________________________ Because ______________________________________________________________________ _________________________________________ Signature of Parent/Guardian

___________________________ Date

_________________________________________ Signature of Caregiver

___________________________ Date

The Salvation Army Child Development Center Application for Enrollment

Student Name: ______________

Screening Consent The first five years of life are very important to your child because this time sets the stage for success in school and later life. During infancy and early childhood, many experiences should be gained and many skills learned. It is important to ensure that each child’s development is proceeding without problem during this period; therefore, we are interested in helping you follow your child’s growth and development. Screening is a process to determine if a child has any developmental concerns that may require further attention and follow-up. Assessment is the process to monitor growth and development of certain skills and knowledge on an ongoing basis. Screening and assessment are directly linked to lesson planning and meeting the individual needs of children. Our goal is to ensure that your child is prepared to enter kindergarten at the age of five. The Salvation Army Child Development Center is going to administer the Ages and Stages Questionnaire for all children in our care. This developmental screening will be administered at least twice per academic year. Information gathered from the observations and screenings will be used to help your child with developmental growth and success. These results are confidential and will be shared with you in writing or in a documented parent-teacher conference. Please indicate if you would like your child to be screened while in our care. _____ I give permission for my child to be screened. _____ I do NOT give permission for my child to be screened. Child’s Name: __________________________________________________________________ Date of Birth: ___________________ If child was premature, original due date: __________________ Parent/Guardian’s Printed Name: _____________________________________________________ Home Phone: ___________________ Work: __________________ Cell: ___________________ _________________________________________ Signature of Parent/Guardian

___________________________ Date

Mission Statement The goal of The Salvation Army Child Development Center is to provide a high quality, affordable and accessible preschool program for children, opportunities for parent engagement and on-going professional development for our staff. We aim to provide the necessary skills, such as social, motor, early literacy, and number awareness, for each and every child in order for them to be successful learners and ready for kindergarten. The CDC supports The Salvation Army’s mission to preach the gospel of Jesus Christ and to meet human needs in His name without discrimination. We hope your time here is wonderful and we look forward to serving your family!

The Salvation Army Child Development Center Application for Enrollment

Student Name: ______________

Parent/Guardian Rights and Responsibilities You have the right to  Visit the center at any time during our operating hours.  Volunteer in the classroom and/or attend field trips.  Request a conference with your child’s teacher(s) and/or Director anytime during operating hours.  Be informed of center activities/events and learning activities.  Know that your child is being physically, mentally and emotionally nurtured and cared for. You are responsible for  Bringing you child clean, well-rested and dressed properly for the weather conditions on a daily basis.  Picking up your child in a timely manner when notified by staff of illness or injury.  Providing personal care items and special dietary foods as needed for your child.  Paying all tuition payments and fees in a timely manner and in accordance with our payment policies.  Observing all policies and procedures set forth in our Parent Handbook.  Having you child at the center by 9:00 am.  Being available to talk to your child’s teacher at drop off and pick up.  Attending parent conferences and parent meetings as scheduled.

Current Fee Schedule Weekly Tuition Rates

Miscellaneous Fees

Infants:

$ 170

Registration Fee:

$ 80

Toddlers:

$ 158

Late Payment Fee:

$ 5.00/student

Two’s:

$ 140

Late Pick Up Fee:

$ 2.00/minute

Three’s:

$ 133

Returned Check Fee:

$25.00

Four’s/Five’s:

$ 124

VPK Wrap:

$ 82

Please retain a copy of this page for your records.