Enrollment form!

Your Child

Child's Name*

First Last

Child's DOB*

Child's Gender*

Female

Male

Child's SSN/ITIN

Personal Information

Parent Name*

First Last

Parent DOB*

Relationship to Child*

SSN/ITIN*

Driver's Licence

Address*

Street Address Address Line 2 City State ZIP Code

Phone

Cell*

Email*

Employment Information

Employer

Working Hours

Address

Street Address Address Line 2 City State ZIP Code

Phone

Parent/Guardian 2 - Personal Info

Parent Name*

First Last

Parent DOB*

Relationship to Child*

SSN/ITIN*

Driver's Licence

Address*

Street Address Address Line 2 City State ZIP Code

Phone

Cell*

Email*

Parent/Guardian 2 - Employment Information

Employer

Working Hours

Address

Street Address Address Line 2 City State ZIP Code

Phone

Emergency Contacts

Emergency contact to notify if the parents/guardians cannot be reached.

Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Relationship to Child*

Phone

Cell*

Authorized to pick up child?

Yes

This person can only pick up your child with further written consent

2nd Emergency Contact

Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Relationship to Child*

Phone

Cell*

Authorized to pick up child?

Yes

This person can only pick up your child with further written consent

3rd Emergency Contact

Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Relationship to Child*

Phone

Cell*

Authorized to pick up child?

Yes

This person can only pick up your child with further written consent

Child's Health

Physician's name*

First Last

Physician's Address*

Street Address Address Line 2 City State ZIP Code

Public Aid Card / Insurance / Policy Number*

Date of last Tetanus shot*

Allergies to medication*

Regularly taken medication*

Medical concerns*

Physical handicaps*

Food restrictions*

Food dislikes*

Special names for objects*

Fears*

Special needs*

Is your child toilet trained?*

Yes

No

Other information that would be beneficial for your child's teacher to know

General Infomation

Pledge of Allegiance*

I/We understand each day will start with the Pledge of Allegiance, following with the song "My Country 'tis of Thee", to encourage country pride and spirit. Grace is said before lunchtime, an example of which follows: "GOD is good, GOD is great, let us thank him for our food, our family, our friends, and our school and bless our home, AMEN"

Trips, Excursions and Public Facilities authorization*

I/We authorize The Ivy Academy of Early Learning Inc. to take our child on walking trips, special excursions and to nearby public park facilities. I/We also authorize the child to ride as a passenger in the vehicle owned or leased by the facility. I understand that such trips are under the supervision of the center and that health and safety precautions are taken in compliance with the safety of the Department of Children and Family Services standards for licensure.

Emergency Medical Information/Authorization*

I/We give The Ivy Academy of Early Learning Inc. permission to take my child to an approved hospital emergency/immediate care center and/or call "911" in case of sudden illness or accident. Additionally, I specifically constitute and appoint The Ivy Academy of Early Learning Inc. my true and lawful attorney, for purposes of authorizing medical treatment to, and the performance of any procedure (basic first aid and CPR) determined to be necessary before/after consultation with Emergency or Family Physician on my child.

If you have medical exemptions due to religious reasons, a notarized letter must be on file, sign by both legal guardians and religious authority.

Program Contract

What school are you applying for?*

How many days per week do you need childcare?*

Drop off time (hours of care)*

:

What time will you drop off your child to school?

Pickup time (hours of care)*

:

What time will you pickup your child from school?

What classroom would you like to enrol your child in?

*Rates are weekly and can vary based on co-pays/sliding scales

What classroom would you like to enrol your child in?

*Rates are weekly and can vary based on co-pays/sliding scales

I attest that the information I provided is true.*

I attest that the information I provided is true. By signing below I agree to the terms of the information that was provided to me in the Parent Information/Rate Sheet, and I understand all of what I have read and signed

Enrollment Form

Your Child

Personal Information

Employment Information

Parent/Guardian 2 - Personal Info

Parent/Guardian 2 - Employment Information

Emergency Contacts

2nd Emergency Contact

3rd Emergency Contact

Child's Health

General Infomation

Program Contract