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South Park Christian Child Care
Enrollment Agreement

 

I. Children Enrolled
Full Name
Birthdate
00/00/0000
Sex
M/F
Date Enrolled
00/00/0000
II. Family Information
Parent or Repsonsible Party
Full Name
SS#
Address
Phone
   

Children and Adults * Living in the home
Name
Age
Relationship
1
2
3
4
5
6
* Age of Adults not required

Church Affiliation
Pastor's Name
Church Name
Church Address

Attendance (choose one)
 
How would you describe your relationship with the Lord?

Parent's Employment
Mother's Employer
Employer's Address
Employer's Phone
 
Working Days (check all that apply)
Sunday
Hours
Monday
Hours
Tuesday
Hours
Wednesday
Hours
Thursday
Hours
Friday
Hours
Saturday
Hours
 
Father's Employer
Employer's Address
Employer's Phone
 
Working Days (check all that apply)
Sunday
Hours
Monday
Hours
Tuesday
Hours
Wednesday
Hours
Thursday
Hours
Friday
Hours
Saturday
Hours
 
Alternate Phone
III. Emergency Information
Person to contact if applicant unavailable
Name
Relationship
Phone
   

Preferred Doctor

Preferred Hospital
Name
Name
Address
Address
Phone
Phone
 

Insurance Company
Name
Group No.
ID No.
Special Instructions
 
IV. Information on Child(ren)
Enter the name of each child you are enrolling in the spaces
labeled A, B, and C. Answer all questions for each child in
the spaces provided under his/her name.

 
A
B
C
Name
 
1. What hours/days per week will child be at South Park?
2. How will child go to and from home?
3. Does child take a mid-day nap or rest? If so, when and how long?
4. What hour does child go to bed at night?
5. Does child dress/undress him/her self?
6. At what age was child potty-trained?
7. What are the child's favorite play activities at home?
8. Does child have neighborhood playmates?
9. What are the child's most liked foods?
10. What are the child's least liked foods?
11. Are there any foods that child should not be allowed to eat for medical or religious reasons?
12. Does child have any handicaps or other known problems that we should be aware of?
13. Does child have special fears?
14. Exceptions, special instructions / other considerations. (ie. Religion, and ethnic holidays; limitations on use of play equipment etc.)
V. Authorization and agreements

A. I AGREE THAT:
Choose
   
1. My Child(ren) will be called for promptly unless prior arrangements have been made.  
   
2. My Child(ren) have my permission to use all of the play equipment and participate in all of the activities provided. (If exception(s), explain)
   
3. Required medical and immunization records on my child(ren) will be provided.  
   
4. Any pictures taken of my child(ren) may be used in newspapers, displays, bulletin boards, or other types of educational publications.  
   
5. South Park will be notified promptly of any changes in family that would affect child(ren)'s attendance, activities or behavior. (This includes updating information on this form).  
   
6. My child(ren) will be provided an extra set of clean clothing, a toothbrush, and other personal items that may be requested by the center.  
   
7. I will pay for services rendered as outlined in the weekly tuition schedule.  
   
8. I will provide a signed emergency medical care release form and signed permission for field trips on the first day South Park provides care for my child(ren).  
   
B. AT THE END OF THE DAY, OR DURING ANY DAY, MY CHILD(REN) MAY BE RELEASED ONLY TO THE PERSONS SIGNING THIS FORM OR TO THE FOLLOWING PERSONS:  
Full Name
Phone
Relation to me
 
By submitting this form you agree that all information provided is complete and true to the best of your knowledge.
   
Name
Date
Name
Date
   
   

 

 

 

 

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