Ages In Stages Day Care :: Registration

Registration Form

(Circle One)

Child’s Name (first, middle, last) ___________________________________ M F

Nickname ____________________ Date of Birth _______________

Address ________________________________________________________________

Home Phone ( ) __________________

Enrollment Date:__________________ Days in Attendance : Monday Tuesday

Wednesday Thursday Friday

Hours of Attendance: Arrival Time __________ Departure Time __________

Parent or Guardian ______________________________________________________

Home Address ___________________________________________________________

Home Phone ( ) __________________ Work Phone ( ) __________________

Cell Phone ( ) ___________________

Employed by ____________________________________________________________

Parent or Guardian ______________________________________________________

Home Address ___________________________________________________________

Home Phone ( ) __________________ Work Phone ( ) __________________

Cell Phone ( ) ___________________

Employed by ____________________________________________________________

List Siblings living in the home Age School Attending

________________________________________________________________________

Emergency Procedures

Persons to Notify:

Name _______________________________ Relationship_______________________

Address _________________________________________________________________

Home Phone ( ) __________________ Work Phone ( ) __________________

Cell Phone ( ) ___________________

Name _______________________________ Relationship_______________________

Address _________________________________________________________________

Home Phone ( ) __________________ Work Phone ( ) __________________

Cell Phone ( ) ___________________

Plan alternate care if child is ill:

Name _________________________________ Relationship_______________________

Address _________________________________________________________________

Home Phone ( ) __________________ Work Phone ( ) ________________

Cell Phone ( ) ___________________

Who has permission to pick up your child / children?

(Other than the parent or Guardian):

Name _______________________________ Phone ( ) _______________________

Milestones

Has your child learned to … (Circle One)

Say Nursery Rhymes? Yes No

Listen to stories? Yes No

Sing Songs? Yes No

Dress him / her self independently? Yes No

Recognize and name common objects? Yes No

Count? Yes No

to what number? __________

Name Basic Colors? Yes No

Has your child ever attended any type of Yes No

preschool or childcare facility before?

What do you hope your child will gain from his / her childcare experience?

(please explain) __________________________________________________________________

__________________________________________________________________

Is your child Toilet Trained? Yes No

Please describe briefly assistance if needed and words used if any

__________________________________________________________________

Does your child nap? Yes No

At what time? ______________

Does your child play well in-group situations? Yes No

Are there any children in the neighborhood your child plays with and what is the age range?

__________________________________________________________________

Does your child follow simple one-step directions? Yes No

(if age appropriate)

What is the method of behavior correction used in your home? __________________________________________________________________

__________________________________________________________________

Do you have any concerns about the aspects of your child’s

development? Yes No

if yes please explain

__________________________________________________________________

Does your child have any special fears? Yes No

if yes please explain

__________________________________________________________________

We would like to share family lifestyles and cultures. The best way to do this is to learn more about one another and the way that we live within our families. We would welcome anything that you feel you could share.

Food and Family Recipes or any specific foods your child likes to eat or foods that your child is allergic to or cannot have due to cultural beliefs __________________________________________________________________

Music

__________________________________________________________________

Art or Craft Techniques

__________________________________________________________________

How we celebrate holidays

__________________________________________________________________

Family Hobbies & Entertainment

__________________________________________________________________

Family Jobs & Responsibilities

__________________________________________________________________

Family Videos or Old Movies

__________________________________________________________________

Medical Information

Does your child have any problems with vision, speech, or hearing? Yes No

if yes please explain

__________________________________________________________________

Are there any foods or beverages your child should not have? Yes No

Any allergic reactions? Please explain

__________________________________________________________________

Does your child have any health problems that we the staff

should be aware of? Yes No

__________________________________________________________________

Please List Any Illness that your child has had…

Allergies____________________

Asthma____________________

Frequent Colds____________________

Stomach Aches____________________

Earaches____________________

High Fevers____________________

Sore Throats____________________

Doctors Information

Doctor’s Name_____________________________________________________

Address______________________________ Phone Number ( ) ___________

Hospital Preference ___________________ Date of Last Physical _____________

Dentist Name__________________________

Address______________________________ Phone Number ( ) ___________

Date of Last Exam ____________________

Medical Consent Form

I, ______________________________, give my permission that

______________________________ may be given emergency treatment by a qualified childcare provider at Ages in Stages Childcare, when I cannot be notified.

I authorize and consent to medical, surgical, and hospital care in the event of an emergency to be performed by a licensed physician or Hospital aid care attendant when deemed necessary to safeguard my child’s health.

I also give my consent in the event of an emergency for my child to be transported by ambulance or aid car to an emergency center for treatment.

I certify or declare under penalty of perjury under laws of the State of Washington that the foregoing is true and correct.

Parent or Guardian (print) _____________________________________________

Social Security Number ______________________________

Home Phone ( ) __________________ Work Phone ( ) __________________

Cell Phone ( ) ___________________

Signature __________________________________________ Date _______________

Parent or Guardian (print) _____________________________________________

Social Security Number ______________________________

Home Phone ( ) __________________ Work Phone ( ) __________________

Cell Phone ( ) ___________________

Signature __________________________________________ Date _______________

Insurance Information

Name of Insurance Company________________________________________________

Member Policy Number ____________________________________________________

Name of Policy Holder_____________________________________________________

Employer ____________________________________________________________

Financial Agreement

Child’s Name ________________________________________

Parent or Guardian ________________________________________

Please read this agreement carefully and sign below, indicating that you accept these terms of payment, tuition, registration fees and late fees. A copy will be kept at all times in your child’s file.

Days of care needed are ________________________________________

Arrival Time ____________________ Departure Time ____________________

Since the Washington State Licensing laws limit the number of children per teacher, and class assignments are made accordingly. Our fee schedule is set to cover the expense of operating at a full capacity; it is not possible to hold your child’s space without a fee.

Source of Payment ________________________________________

Registration fee is $100.00 per child (non-refundable) per year

Over-Time rate is $1.00 per minute per child

Late Payment fee is $10.00 PER DAY

All fees must be paid in advance. Payment not received on time per this agreement may result in termination of childcare.

I agree to pay my Tuition:

Weekly __________ Bi-Weekly __________ Monthly __________

I agree to promptly notify the center director verbally and in writing of any changes to the Financial and Subsidized agreements stipulated.

Signature __________________________________________ Date _______________

Subsidized Financial Agreement

At this time my child’s care is subsidized by ___________________________

(name of agency)

My Responsibility is $____________________

I understand that I am fully responsible for my portion of the tuition in ADVANCE.

Payments not received on time per this agreement may result in the termination of my child’s care.

I agree to pay my portion of the Tuition:

Weekly __________ Bi-Weekly __________ Monthly __________

I agree to promptly notify the center director verbally and in writing of any changes to the Financial and Subsidized agreements stipulated. I have read and understand both agreements and comply with the policies and procedures at Ages in Stages Childcare.

Signature ________________________________ Date _______________

Ongoing Consent Form

Parental Ongoing consent form for

Child’s Name __________________________________________

_____ Emergency Procedures: I give my permission for the center director or person in charge to remove my child in the event of an emergency.

______ Field Trip Permission: I give the director or Designee Permission to remove my child for short trips such as visits to the park and nearby outings. Permission slips will be sent home for special events.

_____ Health Services: I give my permission for my child to receive health promoting screening services provided at the childcare facility, such as vision, hearing, and dental.

_____ Photographs: I give my permission for the childcare facility to take photos of my child for the purpose of posting on bulletin boards, cubbies, etc., sole purpose of good intentions only.

_____ Grievances: I will communicate my grievances honestly and directly to the center director.

I have read the registration forms and completely and agree to the preceding conditions.

Signature ________________________________ Date _______________