Mother/Father/Guardian Information (List only individuals who have legal custody of child. If mother is not listed, or if guardian is not a parent, legal proof of custody must be provided.)
Name:
SSN:
Home Address:
City:
State:
Zip:
Home Phone:
Cell Phone:
Work Phone:
Employer:
Email Address:
Employer Address:
Mother/Father/Guardian Information (List only individuals who have legal custody of child. If mother is not listed, or if guardian is not a parent, legal proof of custody must be provided.)
Name:
SSN:
Home Address:
City:
State:
Zip:
Home Phone:
Cell Phone:
Work Phone:
Employer:
Email Address:
Employer Address:
EMERGENCY CONTACT INFORMATION
Persons authorized to pick-up the child daily:
Persons to be contacted in case of illness, accident or emergency and authorized to pick-up the child from the school if the parents or guardians cannot be reached (Minimum of 2 required)
Name:
Address:
Phone:
Relationship:
Name:
Address:
Phone:
Relationship:
Child's Physician:
Phone:
Child's Dentist:
Phone:
List allergies and intolerance to foods, medications, or other substances
Action to be taken
AUTHORIZATION FOR EMERGENCY MEDICAL CARE (Please Note: This authorization must be NOTARIZED)
If I cannot be contacted in an emergency situation, I authorize the centers staff to obtain emergency medical treatment for my child.
Signature of Parent or Guardian:
Date:
Subscribed and Sworn to before me this
day of
,
Notary Public:
My Commission Expires:
IDENTITY VERIFICATION FOR OFFICE USE ONLY
Place of Birth:
Date of Birth:
Birth Certificate Number:
Date Issued:
Other form of Proof:
CHILD'S PROFILE
FAMILY
Mothers Occupation:
Fathers Occupation:
Our family members (brothers, sisters,grandparents, etc.) living at home:
Name
Age
Relationship
Other family members living in this community:
Name
Age
Relationship
HEALTH
What communicable diseases has the child had?
Measles (Big Red)
Measles (3 day)
Mumps
Chicken Pox
Whooping Cough
Other
Any chronic physical problem?
Type of accommodations needed*:
Any developmental or learning needs
Type of accommodations needed*:
*If special accommodations are needed, a current copy of the child's IEP or ISP is required
MEDICATIONS
Are any medications given regularly? (Please list medications and reason)
No
Yes
Brand of infant formula (if applicable):
Please Note: It is Minnieland's policy to feed infants on demand unless other written instructions are on file from the child's physician.
SPEECH
Describe your child's speech:
Rapid
Slow
Moderate
Clear
Talks Constantly
Seldom Speaks
Uses Many Words
Uses Few Words
Talks Only During Play
TOILETING
Does your child have any special needs?
No
Yes If so, please explain:
SLEEP PATTERNS
What time does your child go to bed?
Awaken?
Does he/she walk, talk, cry out at night?
No
Yes
Does he/she take anything to bed with them?
What is his/her mood upon awakening?
Does he/she take naps:
No
Yes
Typical time of nap?
INTERESTS
Has he/she had experience playing with other children?
With what age child does he/she prefer to play?
What are his/her favorite activities at home?
Does he/she like to:
Be Read to?
Listen to music?
Play outdoors?
Can he/she ride a tricycle?
No
Yes
Has he/she had experience with:
Clay?
Scissors?
Easel Painting?
Blocks?
Puzzles?
Finger Painting?
SCHOOLING
Please list any previous school and/or child care center enrollment:
Name of school/child care center
City/Town
State:
Date:
Name of school/child care center
City/Town
State:
Date:
Is your child attending another school concurrently with our program?
No
Yes
Name of School
Grade of Class Level
COMMENTS
In what particular ways can we help your child this year?
Describe your child briefly (personality, abilities, etc)
FINANCIAL AGREEMENT
I
(please print name), the parent/guardian of
agree to pay my child's tuition no later than Monday of the current week. If i have not paid by Wednesday of the current week, I understand that I will be charged a late fee. I also understand that if I do not pick my child up by the centers closing time, I will incur a charge of $1.00 per minute. In the event that my child's tuition account becomes two weeks in arrears, I understand that my child care services with Minnieland will be terminated. I also agree to pay all costs and expenses including, without limitation, court costs and reasonable attorney fees incurred by Minnieland Private Day School, Inc. in connection with the collection of tuition and the enforcement of this agreement.
Parent/Guardian Signature
Date:
HOLD HARMLESS AGREEMENT
I
(please print name), the parent/guardian of
agree to release and hold harmless Minnieland Private Day School, Inc. and its employees, from any accident or harm that may occur should I retain services of any Minnieland employee for the care of my child(ren) outside the child care center. I understand that Minnieland Private Day School, Inc. does not condone or encourage its employees to babysit for parents of enrolled children outside of the child care center. If I retain the services of any Minnieland Private Day School, Inc. employee in such capacity, Minnieland Private Day School, Inc. has no responsibility and is held harmless from any incident which may occur.
Parent/Guardian Signature
Date:
MINNIELAND POLICIES
I understand that my child must not be left on school grounds without supervision. I agree to walk my child into the school each morning and release my child to a teacher before leaving my child.
I understand that all required forms must be completed and on file at the center before my child may attend.
I understand that no child may be released to anyone except parents/guardians without written permission. I understand that Minnieland will release children to either parent unless a court order indicating sole custody is provided to the center Director. I agree to give the center a list of all persons authorized to pick up my child.
I understand that no medication will be administered without written permission from parents.
I agree to support and reinforce the schools rules and procedures that concern the health and safety of my child and other children
I understand that the Director will notify me whenever my child becomes ill and I agree to pick-up my child or make arrangements to have my child picked up by and authorized individual within one hour of notification.
I understand that my child cannot attend the school if he/she has any illness that threatens the health of other children. I understand that Health Department regulations concerning periods of infection will be enforced. I understand that my child must be fever and symptom free for 24 hours before returning to school after an illness. I also understand that prescription medication must be administered to my child at home for 24 hours before he or she can return to school.
I understand that I am required to inform the center within 24 hours of the next business day if my child or any member of my immediate household has developed any reportable communicable disease, as defined by the State Board of Health, except for life threatening diseases which must be reported immediately.
I understand that child care services may be terminated for any of the following reasons:
My child's tuition account becomes more than two weeks in arrears.
Failure to respond in a timely manner when contacted by the center to pick my child up when he or she is sick.
Failure to adhere to the 24 hour illness recuperation period.
Failure to notify the center, in advance, if my school age child will not be attending after-school care.
Failure to provide the center with up-to-date emergency contact information for my child.
Minnieland does not receive parental support and help if my child is found to have a learning or behavioral problem. This includes failure to attend parent conferences, and to follow through with medical and/or educational specialists.
My child's behavior pattern threatens his or her own health and safety or threatens the health and safety or other children and staff.
Parents/guardians are no longer supportive of Minnieland's programs and philosophy and become negative and uncooperative in their actions and opinion which may undermine the operation of the school.
Parents who are repeatedly late will be asked to make other child care arrangements.
PLEASE READ AND SIGN:
I have read the policies in the Minnieland Parent Handbook and understand their application to me and my child.
