Parent Interview/ Application Form€¦ · Web viewCreative Kids Center. Preschool Registration...

Creative Kids CenterPreschool Registration Form

Date________________ How did you hear about us?___________________________

Child’s Name__________________________________________________________

Nickname_________________________________________ Male_____ Female____

Child’s Birthday__________________________ Child’s Age_____________________

Child Lives With: [ ] Both Parents [ ] Mom [ ] Dad

[ ] Other (Please Specify) _________________________________

Child’s Address________________________________________________________

___________________________________________________________________

Contact Info:

Mom/Guardian Name____________________________________________________

Home Phone___________________________ Cell Phone_______________________

Work Phone___________________________ Email___________________________

Dad/Guardian Name____________________________________________________ Home Phone___________________________ Cell Phone_______________________

Work Phone___________________________ Email___________________________

Emergency Contact Person________________________________________________

Contact’s Home Phone___________________ Cell Phone________________________

Emergency Contact Person________________________________________________

Contact’s Home Phone___________________ Cell Phone________________________

Enrollment Days/Hours

There is an annual registration fee of $50 due upon enrollment.10% discount if yearly tuition is paid in full by 9/1/18.

Tuition is divided into 10 monthly payments.Payment #1 is due August 1 & is allocated for June 2019.

Payment #2 is due on the first day of school.Payments 3-10 are due on the 1st of the month October through May.

CHILD’S NAME: _______________________________________________

Toddlers (2 hours)

5 days - 9:30-11:30 or 1:00-3:00 $2600 per year ($260/month for 10 months)




Morning Afternoon

_____ (5 days) 9:30-11:30 _____ (5 days) 1:00-3:00_____ (4 days) 9:30-11:30 _____ (4 days) 1:00-3:00_____ (3 days) 9:30-11:30 _____ (3 days) 1:00-3:00_____ (2 days) 9:30-11:30 _____ (2 days) 1:00-3:00_____ (1 days) 9:30-11:30 _____ (1 day) 1:00-3:00 *Please specify which days: _________________________

Multi Age Program (3 hours)5 days - 8:30-11:30 or 12:00-3:00 $3000 per year ($300/month for 10

months)4 days - 8:30-11:30 or 12:00-3:00 $2700 per year ($270/month for 10



months)Morning Afternoon

_____ (5 days) 8:30-11:30 _____ (5 days) 12:00-3:00_____ (4 days) 8:30-11:30 _____ (4 days) 12:00-3:00_____ (3 days) 8:30-11:30 _____ (3 days) 12:00-3:00_____ (2 days) 8:30-11:30 _____ (2 days) 12:00-3:00 *Please specify which days: _________________________

Creative Kids Center, Inc.CHILD EMERGENCY INFORMATION CONTACT FORM

(Please do not leave any question blank)

CHILD’S NAME BIRTHDATE

PARENT #1 NAME PARENT #2 NAME

CHILD’S HOME ADDRESS

HOME PHONE EMAIL ADDRESS (In the event of an injury or illness requiring medical attention, staff will attempt to contact the parents)

Parent #1 Employer Work Number

Cell Number

Parent #2 Employer Work Number

Cell Number

If Staff is unable to reach parent, we will attempt to reach in order listed a contact person who will assume responsibility for care of child in an emergency & are also authorized to pick up child. The emergency contacts you list should live in the AREA & have TRANSPORTATION.

CONTACT #1 PHONE NUMBER

ADDRESS RELATIONSHIP

CONTACT #2 PHONE NUMBER

ADDRESS RELATIONSHIP

PHYSICIAN PHONE NUMBER

CLINIC NAME & ADDRESS

DENTIST PHONE NUMBER

CLINIC NAME & ADDRESS

LIST ANY KNOWN ALLERGIES

DATES OF LAST TETANUS SHOTS AND IMMUNIZATIONS WILL BE FOUND IN CHILD’S FILE

OTHER SIGNIFICANT MEDICAL INFORMATION

NAME OF MEDICAL INSURANCE CARRIER

POLICY #

I understand that in some emergency situations Creative Kids Center, Inc. will need to contact the Emergency Medical Service (911) before the parent, child’s physician, or other adult who is acting on the parent’s behalf. In the event of a non-life threatening medical emergency, my child should be transported to Hospital. If it is a life threatening medical emergency, I understand that my child will be transported to the nearest hospital.

I give my written permission to Creative Kids Center, Inc. staff to have access to my child’s health information.

I hereby grant permission to the staff of Creative Kids Center, Inc. to take whatever emergency measures are judged necessary for the care and protection of my child while under the supervision of the Center.

PARENT/GUARDIAN SIGNATURE DATE

Permission to Photograph

I, ________________________, give permission for Creative Kids Center, Inc. to (parent/guardian name)

photograph/video my child, ________________________, for the following purposes:

Type of Use: (Please check one)Grant Permission Decline Permission

Still Photographs:Display in Director’s personal scrapbookDisplay in facility’s scrapbook or on bulletin boards, visible to current and prospective families.*Display still photos on preschool website.*Post photos on preschool Facebook pageOther:

Videos:Give video to current parents Post video on preschool website.Post video on preschool Facebook page.Other:

Other (please list):

*Only first name and possibly last initial (in the event of two or more children with the same first name) will be displayed on the facility website/Facebook page.

I understand that it is my responsibility to update this form in the event that I no longer wish to authorize one or more of the above uses. I agree that this form will remain in effect during the term of the present school year of my child’s enrollment.

_____________________________________________________________(Parent/Guardian signature) (Date)

Creative Kids Center, Inc.About Your Child

CHILD’S NAME: _______________________________________________

Please help me become a partner with you in your child’s education. I will only have your child for a short time on this journey through life & I would like to make a contribution that lasts a lifetime. I know my teaching must begin with making your child feel at home in our classroom, as well as help all of the children join together as a learning community made up of unique individuals, each with his/her own learning style, interests & history. Please take a quiet moment to write about your child. What is your child like? What are the things you, as a parent, know that would be important for me to know? What are your child’s interests? I want to know how your child thinks & plays as well as how you see your child as a learner & a person. Thank you for your thoughts & contribution to your child’s learning.

Has your child ever been in child care/preschool before? _________________________

If so, what type (center, family daycare, grandma etc.) __________________________

Was it a positive experience? _____________________________________________

___________________________________________________________________

How does your child feel about being left by his/her mommy/daddy? ________________

___________________________________________________________________

Have there been any recent traumatic situations your child has been exposed to such as a death in the family, divorce, new sibling etc.? _________________________________

___________________________________________________________________

___________________________________________________________________

What is your typical method of discipline? ___________________________________

___________________________________________________________________

___________________________________________________________________

What is your child's temperament? Are they easy going, hard to please, demanding, aggressive, etc.?

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

Any food restrictions? __________________________________________________

___________________________________________________________________

___________________________________________________________________

Favorite foods? _______________________________________________________

Can your child be relied upon to indicate bathroom wishes? _______________________

Words your child uses to indicate bathroom wishes: ____________________________

Sibling Information:

Name ____________________________ age ___________ gender ________

Name ____________________________ age ___________ gender ________

Name ____________________________ age ___________ gender ________

Has your child had experience playing with other children? _______________________

___________________________________________________________________

___________________________________________________________________

What language(s) is/are spoken at home? ____________________________________

Favorite activities, toys, books, games? ______________________________________

___________________________________________________________________

Please feel free to use additional paper for any other comments, information or concerns you would like us to know.

Creative Kids Center, Inc.Your Child’s Health

CHILD’S NAME: ______________________________ D.O.B._______________

CHILD'S HEALTH RECORD: (A copy of your child's immunizations and current physical will be needed before he/she begins school.)

General state of health: _________________________________________________

___________________________________________________________________

___________________________________________________________________

Doctor Name_________________________________________________________

Doctor Phone Number___________________________________________________

Dentist Name_________________________________________________________

Dentist Phone Number __________________________________________________

Are immunizations up to date? _________

(Please attach a copy of immunizations, which includes the signature of the nurse or doctor who administered medications.)

Does your child have any known allergies? (Please be specific.) _____________________ ___________________________________________________________________

Does your child have any medical conditions that we should be aware of? _____________

___________________________________________________________________

CHILD’S NAME: _______________________________________________

Does your child have any speech, hearing or visual problems or does he/she receive any special education services? _______________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

Any restrictions to play or activities? _______________________________________

___________________________________________________________________

___________________________________________________________________

Creative Kids Center, Inc.ENROLLMENT CONTRACT

It is my desire to have my child/children ___________________________ enrolled in the preschool program at Creative Kids Center, Inc.

I have received a copy of the Creative Kids Center, Inc. policy handbook. I have read, understand and agree to abide by the policies contained therein. I further understand that if the policies outlined in this handbook are not adhered to, it will be sufficient cause for the removal of my child/children from the Creative Kids Center, Inc. program.

Please initial next to each item.We want to be sure you understand and agree to these policies.

________ I understand that I must provide a completed medical form to the preschool.

________ I understand the tuition fees are __________ per month for the 10-month school year.

________ I understand that the registration/tuition fees are non-refundable with the exception of children who are accepted into a school district’s UPK program. In order to receive such refund, the acceptance letter must be provided to the Director within 10 days of receipt.

________ I understand there will be no refunds or make-up days if there is a snow day, late start or early dismissal.

________ Furthermore, I understand there will be no refunds or make-up days if my child is absent, arrives late or leaves early.

________ I understand tuition payment is due the first of every month except for September when it is due on the first day of school.

________ I understand that a late fee of $10.00 will be incurred for payments made after the 10th of the month.

_________ I understand that an additional late fee of $10 will be incurred after the 15th of the month for a total of $20 in late fees.

_________ I understand that after the 15th of the month, my child will not be allowed to return to school until tuition plus fees have been paid.

________ I have contracted for the hours of __________ to __________.

________ I understand that I must pick up my child/children on time.

________ I understand the pick up policy for other than parental pick up.

________ I understand the illness policy.

________ I am contracting for the 2018-2019 school year.

________ I understand the behavior policy and have read and shared the preschool rules with my child/children.

________ I understand the returned check policy.

________ I agree to pay the non-refundable June tuition during registration.

____________________________ ___________________Parent(s)/Guardian(s) Date

____________________________ ___________________Sheri R. Zilinskas, M.S. Ed. DatePresident/Educational DirectorCreative Kids Center, Inc.

Parent Interview/ Application Form€¦ · Web viewCreative Kids Center. Preschool Registration...

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