Enrollment Form "*" indicates required fields 1Personal2Medical3Contacts4Schedule InstagramThis field is for validation purposes and should be left unchanged.Operation Name*Select DaycareLittle Christian Academy, Inc.ABC Day CareBob's Day CareStatusNewCompleteIncompleteDuplicateVerificationWPMG VerifiedVerifiedInactiveThis field is hidden when viewing the formNumber StatusReason InactiveSelect BelowFirst ChoiceSecond ChoiceThird ChoicePersonal InformationChild's Full Name First Last NicknameDate of Admission MM slash DD slash YYYY Date of Withdrawal MM slash DD slash YYYY Photo of Child Drop files here or Select files Max. file size: 64 MB, Max. files: 1. Date of Birth MM slash DD slash YYYY AgeGradePreKindergartenFirstSecondThirdSex Male Female Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Child Lives With Both Parents Mom Dad Guardian Custody documents on file? Yes No Consent InformationTransportationI give consent for my child to be transported and supervised by the operation's employees. Check all that apply. For emergency care On field trips To and from home To and from school Field Trips I give consent for my child to participate in field trips. I do not give consent for my child to participate in field trips. Field Trip CommentsWater ActivitiesI give consent for my child to participate in the following water activities. Check all that apply. Water table play Sprinkler play Wading pools Swimming pools Aquatic playgrounds Is your child a competent swimmer? Yes No Does your child have any physical, health, behavioral or other condition that would put them at risk while swimming?If yes, your child is required to wear a life jacket while in or near a swimming pool.Note: A competent swimmer can enter and exit a pool safely on their own, tread water or float on their back for one minute, and swim 25 yards with no assistance. Yes No Receipt of Written Operational PoliciesI acknowledge receipt of the facility's operational policies, including those for the following.Check all that apply. Discipline and guidance Procedures for release of children Suspension and expulsion Illness and exclusion criteria Emergency plans Procedures for dispensing medications Procedures for conducting health checks Immunization requirements for children Safe sleep Meals and food service practices Procedures for parents to discuss concerns with the director Procedures to visit the center without securing prior approval Procedures for parents to participate in activities Procedures for supporting inclusive services Promotion of indoor and outdoor physical activity including criteria for extreme weather conditions Procedures for parents to contact Child Care Regulation (CCR), DFPS, Child Abuse Hotline and CCR website MealsI understand the following meals will be served to my child while in care.Check all that apply. None Breakfast Morning snack Lunch Afternoon snack Supper Evening snack Days and Times in CareMy child is normally in care on the following days and times.Monday AM Hours : Minutes AM PM AM/PM Monday PM Hours : Minutes AM PM AM/PM Tues AM Hours : Minutes AM PM AM/PM Tuesday PM Hours : Minutes AM PM AM/PM Wednesday AM Hours : Minutes AM PM AM/PM Wednesday PM Hours : Minutes AM PM AM/PM Thursday AM Hours : Minutes AM PM AM/PM Thursday PM Hours : Minutes AM PM AM/PM Friday AM Hours : Minutes AM PM AM/PM Friday PM Hours : Minutes AM PM AM/PM Saturday AM Hours : Minutes AM PM AM/PM Saturday PM Hours : Minutes AM PM AM/PM Sunday AM Hours : Minutes AM PM AM/PM Sunday PM Hours : Minutes AM PM AM/PM Receipt of Parent’s RightsI acknowledge I have received a written copy of my rights as a parent or guardian of a child enrolled at this facility.Parent or Legal Guardian SignatureDate MM slash DD slash YYYY Child's Special Care NeedsCheck all that apply. Environmental allergies Limitations or restrictions on child's activities Food intolerances Reasonable accommodations or modifications Existing illness Adaptive equipment, include instructions below Previous serious illness Symptoms or indications of complications Injuries and hospitalizations in the past 12 months Medications prescribed for continuous long-term use Other Other Special Care NeedsExplain any needs selected above.Does your child have diagnosed food allergies? Yes No Food Allergy Emergency Plan Submitted Date MM slash DD slash YYYY Child day care operations are public accommodations under the Americans with Disabilities Act (ADA), Title III. To learn more, visit www.ada.gov/resources/child-care-centers/. If you believe that such an operation may be practicing discrimination in violation of Title III, you may call the ADA Information Line at 800 514-0301 (voice) or 800 514-0383 (TTY).SignatureSchool Age ChildrenMy child attends the following schoolSchool Area Code and Phone No.My child has permission to walk to or from school or home ride a bus be released to the care of their sibling younger than 18 years old Authorized pick up or drop off locations other than the child’s address. Child's required immunizations, vision and hearing screening are current and on file at their school. Yes Parent or Guardian InformationPlease click the button below to Add Details about each parent or guardian Has parental responsibility Legal Name Relationship to Child Phone Photo Actions Edit Delete There are no Parent or Guardians. Add Parent or Guardian Maximum number of parent or guardians reached. Emergency Contact(s) Legal Name Relationship to Child Phone Actions Edit Delete There are no Emergency Contacts. Add Emergency Contact Maximum number of emergency contacts reached. Medical InfomationCommon Childhood Medical IssuesConstipationConvulsionsDiarrheaFainting SpellsFrequent ColdsFrequent Ear InfectionsFrequent Sore ThroatsLiceRingwormSkin RashSoilingStomach UpsetsUrinary ProblemWormsOtherCommon Childhood IllnessesAsthmaBronchitisChicken PoxDiabetesHeart DiseaseHepatitisImpetigoMeaslesMumpsGerman MeaslesPolioScarlet FeverTuberculosisWhooping CoughOtherOther Medical IssuesOther IllnessesList of Medications the Child Takes(One per line. Click the "plus sign" to add a line) Add RemoveVaccines Child's Name Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. Health Insurance Details Authorized Pickup ListAuthorized Contact Legal Name Relationship to Child Actions Edit Delete There are no Authorized Contacts. Add Authorized Contact Maximum number of authorized contacts reached. Developmental and Care InformationDetails about the child’s routines, likes/dislikes, and any special needsLanguages spoken at home Select Below English Spanish Other Legal Documentation (if applicable)Custody arrangements or court orders concerning the child This information allows daycares to provide tailored care, ensure the child’s safety, and handle emergencies efficiently.Upload Files Row ID Document Type Notes File Actions Edit Delete There are no Files. Add File Maximum number of files reached. SignatureI understand that my application is not a determination of eligibility for assisted housing/ public housing. I will not immediately be offered housing, but will be placed on a Waiting List with other applicants, who may claim and/or are entitled to LOCAL PREFERENCE. The eventual extension of housing benefits will be based upon my place on the waiting list.Legal Consent*Consumer Disclosure Regarding Conducting Business Electronically, Signing Documents Electronically, and Receiving Electronic Notices and Disclosures Please read the information below, carefully, as it concerns your rights. eSignatures are an efficient way to execute an agreement with the same legal force and effect of a handwritten or “wet ink” signature. By signing this document you are agreeing that you have reviewed this Consumer Disclosure and consent and intend to transact business electronically; to use electronic signatures instead of wet ink signatures and paper documents, and to receive notices and disclosures electronically. You are not required to sign documents electronically or to receive notices and disclosures electronically. If you prefer not to transact business electronically, you may request paper copies from the “sending party” and withdraw your consent at any time, as described below. Scope of Consent By utilizing this Service, you agree to receive electronic signature documents with all related and identified documents, notices, and disclosures provided during your relationship with the “sending party.” You may withdraw your consent, at any time, by following the procedures outlined below. Paper Copies You are not required to sign documents electronically, or receive notices or disclosures electronically, and may request paper copies of documents or disclosures, if you prefer. You also have the ability to download and print any signed or unsigned documents sent to you through the electronic signature service. We may also email you a copy of all documents you sign using the electronic signature service. If you wish to receive paper copies instead of electronic documents you may close this web browser and request paper copies from the “sending party” by following the procedures outlined below. The “sending party” may apply a charge for additional expenses incurred by printing and mailing paper copies. Withdrawal of Consent You may withdraw your consent to receive electronic documents, notices or disclosures at any time. In order to withdraw consent you must notify the “sending party” that you wish to withdraw your consent to transact business electronically and to provide your future documents, notices, and disclosures in paper format. If at any time, after withdrawing your consent you choose to use our electronic signature system your use of this Service will, once again, evidence your consent to receive documents, notices, and disclosures, electronically. You may withdraw your consent to receive electronic notices and disclosures or execute an electronic signature by following the procedures described below. Withdrawing your consent, requesting a paper copy, or updating your contact information You always have the ability to download and print any documents sent to you through our electronic signature system. To withdraw your consent to conduct business electronically, sign documents electronically, and receive documents, notices, or disclosures electronically, please contact the “sending party” directly; by telephone, by email (sent to the “sending party” with any of the topics outlined below stated in the subject line of your email) or by postal mail to their mailing address specified to receive such notices. “Withdrawal of Consent To Transact Business Electronically” To allow the “sending party” to identify and facilitate your withdrawal of consent to transact business electronically, please provide your name, email address, the date on which you are withdrawing your consent, your telephone number and mailing address. “Requesting A Paper Copy” To allow the “sending party” to identify you to provide a paper copy of the document requiring your signature, the notice, or disclosure, please provide the sending party with your name, email address, mailing address, telephone number, and name of the document of which you are requesting a paper copy . “Update Your Contact Information” To allow the “sending party” to identify you in order to update your contact information, please provide them with your name, email address, mailing address, and telephone number. The “sending party” will inform you of any fees related to costs for printing and mailing paper copies or your withdrawal consent to transact business electronically. I agree to the terms and conditions.Misc Comments
