CONTACT INFORMATIONChild‘s Name : Birth Date :

Mother/Guardian : Father/Guardian :

Employer : (Street & City) :Employer : (Street & City) :

Name :

Phone : Relationship :

Name :

Phone : Relationship :

(Phone) :

Other Household Members :

(Phone) :

Second Child : Birth Date :

Third Child :

Home Address :

Parents Home Address (if different from chiId) :

Birth Date :

Phone :

Street : Zip Code :State :City :

PERMISSION TO RELEASE YOUR CHILDFor your child's safety, I only allow children to leave the center with

you the parent(s) enrolling the child

Changes must be made in writing or I.D. will be photo copied.

person(s) you have listed below

Magic KingdomEnrichment Academy, LLC.

HOURS & DAYS OF OPERATION

MEALS & NUTRITION

Care normally begins at 6am and ends at pm. Monday thru Friday

The total fee $ are due every Week Bi-Weekly

Cash / DRS certificate

Payments must be approved.

Form of payment accepted :

Payments for child care is due on Friday or Monday morning. Late fee applies any time after this

Child care will not be provided on the following holidays and/or vacation days :

Additional Services :Friday or Monday morning. Late fee applies any time after this

Annual Fees : For repair, replace, renewing of any items..Amount: $50.00

If you arrive late to pick up your child, the charge is: $1.00 per min.

Sept.

Nov.

Dec.

Jan.

April

May

Labor Day

Thanksgiving Thurs & Fri

Winter Break (dates will be posted)

New Years Day & Martin L. King Day

Good Friday

Memorial Day

July Dependence Da

If the child is not present due to illness or parent vacation the fee policy is the same / if ill a doctors statement is needed to waive fees. One "Week (free) parent vacation is given with notice given one week in advance.

I provide the following meals and snacks based upon the hours of care listed above; Breakfast, AM snack, Lunch, PM snack

Your child may not bring other food of candy from home. (Ex.ceptions made for special occasions)

Parents provide : formula, baby food and food for any speciai diet

ALL OTHER DAYS WILL BE POSTEDFEE POLICY IS THE SAME

First :

** We do not administer any medicine.. Please Administer Medicine during parenting hours. Please notify us if your child is taking any medicine.. I must have written. permission to secure emergency medical treatment.

CHILDS HEALTH

PERSONAL ITEMS

To protect your child and the health of other children, I reserve the right to determine when a child is too ill to be cared for in school. If your child becomes ill in school, I will call you at work and request that you pick up the child. State the name of the parent/guardian to call.

OTHER CHILD CARE PRACTICES

Our plan for caring for your child(ren) includes the following kinds of activities: Early Start Curriculum ,blocks, puzzles, games, educational one on one teaching, field trips, books & audio tapes.

We agree to discuss concerns as soon e.s they arise. If the concern has to do with a child's behavior, we agree to discuss it alone first and decides on how we are going to deal with the problem behavior. If the child is old enough to understand, the child will be included in the plan for dealing with the problem.

We have discuss and agreed upon the following ways to guide each child's behavior: by having several activities for learning and playing in a loving, caring, nutrias & clean environment.

The parent must supply an extra set of clean clothing for each child.

Must be in a zip lock bag with child's name on it.

The parent must supply diapers.We will supply baby wipes.

The child may not bring a favorite toy/blanket to school.

The child may not bring money to schooL

Other : No Baby Bags please (Daycare rules only)

Infant care – If your child is on a bottle or cup it must have his/her name on it daily. We also ask for you to stick with the same type bottle.

TRANSPORTATION

The use of child safety restraints and seat belts as required by TN law, the practices will be observed: Each child safety restraints and seat belt will be used always when being transported. A roll will be kept of all children entering and existing the bus or van.

MISCELLANEOUS

In order to ensure good relations with neighbors and other customers, please observe the following request: Please don't block the drive and most importantly be curtius.

Both provider and parent agree to give 2 weeks notice before childcare is to terminated.

OTHER

The caregiver and parent agree to the following :

***Child(ren) will not be in care longer than 10 hours.

Parent's/Guardian's Signature Date

Parent's/Guardian's Signature Date

Director/Owners Signature Date

MAGIC KINGDOM DOES NOT DISCRlMIANTE AGAINST RACE, COLOR, NATIONAL

ORIGIN, SEX OR HANDICAP.

PERMISSION TO SECURE EMERGENCY

MEDICAL TREATMENT

permission to secure and authorize such emergency medical care and /or treatment asmy child might require while Utider Magic Kingdom's supervision. I agree to pay all cost and fees contingent on any emergency medical care and/or treatment for my child as secured or authorized under this consent that is not covered by provider's insurance.

Note : Every effort will be made to notify parents immediately in case of emergency.

Parent’s Signature Date

I, Parent/guardian of

Age , give Magic Kingdom Enrichment Academy

Magic KingdomEnrichment Academy, LLC.

Magic KingdomEnrichment Academy, LLC.

have received a copy of the Daycare Licensing Requirements for child care centers.I have also received rules, policies and orientation, at Magic Kingdom Enrichment Academy.

Parent’s Signature Date

I, Parent/guardian of

MEDICAL PROBLEMS

18) Has your child ever been with anyone having TB?Yes No

17) Has your child ever had a bumpy, swollen reaction to the TB skin test?Yes No

16) Is your child able to play as hard as other children?Yes No

19) Has your child ever had worms?Yes No

20) Does your child scratch his/her genital areas? Is his/her bottom orgenitals?

Yes No

21) Is your child a hemopblliac (free bladder)?Yes No

22) Is your child on a heart monitor?Yes No

23) Does your child have tubes in his/her ears?Yes No

OLDER GIRLS

1) How old was your doughter when she had first period?Yes No

2) Does she have any problems with her period?Yes No

GENERAL DEVELOPMENT

1) Is your child in a special educalion class in school?Yes No

2) Does your child get along with other children?Yes No

3) Is he/she usually happy?Yes No

4) Does your child have any special problems not indicated above?Yes No

5) When did your child last see a doctor?Yes No

Month Year

Appendix 6-DCHILD'S HEALTH HSTORY CBECKLIST

PREGNANCY AND BIRTH

Chitd‘s Name :

Parent/Guardian’s Name :

Birth Date :

The answer to these questions will help us to know if your child has any medical problems. we need this information in case he/she should become ill and we would be unable to reach you right away. Please circle the right answer. We will go over the checklist with you when you have

1) Were there any problems with prepanancy or tour child's birth?Yes No

2) Was his/her birth weight under 5 ½ pounds?Yes No

3) Did the baby have any problem in the hospital?Yes No

MEDICAL PROBLEMS

4) Has your child ever been in the hospital ovemight?Yes No

5) Is your child taking any medicine?Yes No

6) Any allergies or reactions to medicine, DTP or other shots, or insects?Yes No

7) Has your child had asthma or wheezing?Yes No

8) Does your child have speech or hearing problem?Yes No

9) Has your child bad more than two ear infections in one year?Yes No

10) Has your child had tonsilities?Yes No

11) Does your child have trouble with his/her eyes or seeing?Yes No

12) Has your child had a bladder or kidney infections?Yes No

13) Does he/she have burning when urinating?Yes No

14) Does he/she have seizures, fits or shaking spells?Yes No

15) Have you ever been told your child has a heart murmur?Yes No