Online Enrollment Application ⋆ A Place To Grow

A Place To Grow Children’s Center

Application for Childcare Services

Each family must have a pre-enrollment conference with the director or assistant director to exchange information about the center’s program and the specific needs of the child. The following information is requested to assist the center in providing the best possible individualized care for your child. Please feel free to add any additional information that might be relevant to childcare.

Child's Name(Required)

First Last

Child's Birthday(Required)

If your child will attend on a regular schedule, please indicate below. In addition, each child MUST be signed up to attend on the weekly sign-up sheets.

Monday

Tuesday

Wednesday

Thursday

Friday

Has your child had experience being cared for in a group setting, by a relative, or a non-relative?

By a relative

Non-relative

Has your child had any negative experience with childcare that may affect his/her adjustment to our center?

Does your child have any allergies?

Please list any pertinent information which will help us promote your child’s physical, emotional, social and intellectual wellbeing (potty training successes or difficulties, attachments, special likes/dislikes, home languages, religion, family structure and culture)

Has your child received Birth to Three services?

Yes

No

Is your child receiving services from any outside agencies?

Yes

No

Does your child have an IEP?

Yes

No

Do you have any concerns about your child’s development?

Yes

No

Other children in the family

Name

Age

Gender

To add more names click the + symbol at the end of this row.

Parent/Guardian’s Signature(Required)

First Last

Date(Required)

A Place To Grow Children’s Center

EMERGENCY CONTACT INFORMATION

Child's Name(Required)

First Last

Birthday(Required)

Address(Required)

Street Address City State ZIP Code

Home Phone

Child Social Security Number

Child's Gender

Boy

Girl

Mother's Name(Required)

First Last

Mother's Social Security Number

Email(Required)

Place of Employment

Work Phone Number

Work Address

Street Address City State ZIP Code

Job Title

Work Hours

______________________________________________________________________________________________________________________________

Father's Name

First Last

Email

Place of Employment

Work Phone Number

Work Address

Street Address City State ZIP Code

Job Title

Work Hours

Legal Custody of Child

Max. file size: 32 MB.

Please include a copy of the court order in effect.

______________________________________________________________________________________________________________________________

Individual to contact if parents can not be reached in case of emergency

Name

First Last

Relationship

Address

Street Address City State ZIP Code

Phone

______________________________________________________________________________________________________________________________

Name of Child's Doctor

First Last

Phone

Address of Child's Doctor

Street Address City State ZIP Code

Child's Health Insurance

Health Insurance ID

If emergency medical care is necessary, and I can not be contacted, I authorize the staff member in charge to act in my behalf in granting permission for my child to receive emergency treatment or surgery. If possible, please take my child to following medical facility

I understand that the nearest facility will be used if further transportation would jeopardize my child’s safety.

Parent/Guardian Signature

First Last

Date

A Place To Grow Children’s Center

Evacuation Copy

EMERGENCY CONTACT INFORMATION

Child's Name

First Last

Address

Street Address City State ZIP Code

Home Phone

Child Social Security Number

Child's Gender

Boy

Girl

Mother's Name

First Last

Mother's Social Security Number

Email

Place of Employment

Work Phone Number

Work Address

Street Address City State ZIP Code

Job Title

Work Hours

______________________________________________________________________________________________________________________________

Father's Name

First Last

Father's Social Security Number

Email

Place of Employment

Work Phone Number

Work Address

Street Address City State ZIP Code

Job Title

Work Hours

Legal Custody of Child

Max. file size: 32 MB.

Please include a copy of the court order in effect.

______________________________________________________________________________________________________________________________

Individual to contact if parents can not be reached in case of emergency

Name

First Last

Relationship

Address

Street Address City State ZIP Code

Phone

______________________________________________________________________________________________________________________________

Name of Child's Doctor

First Last

Phone

Address of Child's Doctor

Street Address City State ZIP Code

Child's Health Insurance

Health Insurance ID

If emergency medical care is necessary, and I can not be contacted, I authorize the staff member in charge to act in my behalf in granting permission for my child to receive emergency treatment or surgery. If possible, please take my child to following medical facility

I understand that the nearest facility will be used if further transportation would jeopardize my child’s safety.

Parent/Guardian Signature

First Last

Date

Special Instructions for Pick-Up

Child's Name

First Last

Birth Date

In addition to the custodial parents, I authorize the following individuals to sign my child out of the center on a daily basis. I authorize A Place To Grow to discuss financial account/payment information with these individuals upon pick up/drop off.

Name

First Last

Relationship

Phone

Address

Street Address City State ZIP Code

______________________________________________________________________________________________________________________________

Name

First Last

Relationship

Phone

Address

Street Address City State ZIP Code

______________________________________________________________________________________________________________________________

Name

First Last

Relationship

Phone

Address

Street Address City State ZIP Code

______________________________________________________________________________________________________________________________

Name

First Last

Relationship

Phone

Address

Street Address City State ZIP Code

______________________________________________________________________________________________________________________________

Address

Street Address City State ZIP Code

______________________________________________________________________________________________________________________________

Name

First Last

Relationship

Phone

Address

Street Address City State ZIP Code

Only people on this list may pick up this child from the center. A Place To Grow may give these people account statements or disclose account status to these people

______________________________________________________________________________________________________________________________

Name

First Last

Date

Permission to photograph

A Place To Grow uses audio and video monitoring for quality assurance purposes in our center. The center may take photographs/video and audio of the children during special events or projects for use within the center or in advertising. A Place to Grow holds all video/audio and photos as confidential and will not release without a parent/guardians consent except if required by law in case of an investigation by the West Virginia Department of Health and Human Resources or court subpoena.

As a parent\Guardian of

First Last

I consent for this child to be video and audio taped and /or photographed for use within the center only. A Place To Grow will ask for further consent before releasing these audio and video recordings and/or photos for another purpose.

Name

First Last

Parent/Guardian’s Signature

ONLY COMPLETE THIS FORM IF YOU HAVE A MOUNTAIN HEART CHILDCARE CERTIFICATE

A Place To Grow Children’s Center

Addendum to Parent Agreement for Mountain Heart Childcare Services Clients This addendum serves as a contract between A Place To Grow Children’s Center and Mountain Heart Childcare Services client.

Child's Name

First Last

I understand that all parent fees are due in advance and my child may not attend A Place To Grow until my parent fees are paid for that day

I understand that my Mountain Heart Childcare Certificate only pays for childcare while custodial parents are at work or school (with reasonable transportation time) Therefore, I must come directly from work/school to pick up my child each day. A Place To Grow will routinely verify work hours with employers. If unable to verify with an employer, parents will be required to bring in a written schedule or proof of work hours.

I understand that if I go elsewhere after or before work/school I am responsible for notifying A Place To Grow staff of my plans. I am responsible for the childcare fees from the time I leave work until I pick up my child. If I fail to notify A Place To Grow of my after/before work/school plans and either Mountain Heart or A Place To Grow discover I left work/school earlier than pick up time, I will be responsible for the childcare fees for the entire day. (i.e. I leave work at 1:00, but do not pick up my child until 3:00; I am responsible for the entire day at the hourly use rate) This must be paid in order to return to the center.

I understand that even if I am working, I am responsible for paying for any hours exceeding the maximum hours indicated on my Mountain Heart Certificate.

I understand that my child(ren) must be signed up on the weekly sign up sheets with the approximate drop off and pick up time on a daily basis. I am only guaranteed childcare space if I have signed up in advance. If I reserve a space for my child and do not plan to attend, I must notify A Place To Grow by 12 noon to cancel my reserved spot. In the even that I do not notify A Place To Grow that my child will not be attending I will pay a $5 NO SHOW FEE to cover the cost of planned meals and staff. This must be paid in order to return to the center.

I understand that if I have a full time certificate (20-23 days), my child must attend a minimum of 15 days per month to maintain enrollment with A Place To Grow. In the event I do not use a minimum of 15 days per month, I will withdraw my child from the center.

Name

First Last

Parent/Guardian’s Signature

Today's Date

Notification Request Form

Pesticide Levels 3 and 4

Level 3 EPA Caution (crack and crevice treatments)

Level 4 EPA Warning or Danger (broadcast spraying and fogging)

Do you as a parent or legal guardian wish to be informed at least 24 hours in advance Of the application of Level 3 or 4 pesticides in your child’s day care center?

Please mark the appropriate box and return to the director:

Yes

No

Child’s Name

First Last

Parent or Guardian’s Name

First Last

Address

Street Address City State ZIP Code

Phone

A Place To Grow Children’s Center

Parental Consent Form For Sunscreen Application

Child's Name

First Last

As the parent/guardian of the above child, I recognize that too much sunlight may increase my Child’s risk for skin cancer later in life. Therefore, I give my permission for the staff at A Place To Grow to apply Rocky Mountain Sunscreen SPF 30 to my child, as specified below, when he or she will be playing outside, Especially during the months of April through September and between the hours of 10 a.m. And 4 p.m. I further understand that sunscreen may be applied to exposed skin including but not limited To the face, ears, bare shoulders, arms and legs.

Please check all applicable boxes regarding the type and use of sunscreen for your child:

I have consulted with my child’s health care provider, and I do not know of any allergies or allergic reaction my child may have to Rocky Mountain Sunscreen SPF30

A Place To Grow staff may apply Rocky Mountain Sunscreen SPF30, certified by the AMC Cancer Research Center as a top-quality sun protection product, to my child as described above.

NO FOR MEDICAL REASONS, DO NOT APPLY SUNSCREEN TO MY CHILD UNDER ANY CIRCUMSTANCES.

Parent/Guardian Full Name (please print)

First Last

Date

Online Enrollment Application