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)
4 days - 9:30-11:30 or 1:00-3:00 $2200 per year ($240/month for 10 months)
3 days - 9:30-11:30 or 1:00-3:00 $2200 per year ($220/month for 10 months)
2 days - 9:30-11:30 or 1:00-3:00 $2000 per year ($200/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)3 days - 8:30-11:30 or 12:00-3:00 $2400 per year ($240/month for 10
months)2 days - 8:30-11:30 or 12:00-3:00 $2100 per year ($210/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.