Enrollment Information

 
Center for Enrollment:
First Parent Information-
Name:
Address:
City:
State:
* Zip:
Phone Number:
SSN:
Employer:
Employer Address:
Work Phone #:
Ext #:
Second Parent Information-
Name:
Address:
City:
State:
Zip:
Phone:
SSN:
Employer:
Employer Address:
Work Phone #:
Ext #:
Child/Children Information-
First Child's Name:
*
Date of Birth:
* YYYY-MM-DD
SSN:
Gender:
*
Second Child's Name:
Date of Birth:
YYYY-MM-DD
SSN:
Gender:
Third Child's Name:
Date of Birth:
YYYY-MM-DD
SSN:
Gender:
Fourth Child's Name:
Date of Birth:
YYYY-MM-DD
SSN:
Gender:
 
Address:
(if different from parent address above)

Home Phone #:
Referred by:
Contact People:
First Contact's Name:
*
Relationship:
*
Address:
*
Phone #:
*
Emergency Contact:
*
Authorized to Pick Up:
*
 
Second Contact's Name:
Relationship:
Address:
Phone #:
Emergency Contact:
Authorized to Pick Up:
 
Third Contact's Name:
Relationship:
Address:
Phone #:
Emergency Contact:
Authorized to Pick Up:
 
Fourth Contact's Name:
Relationship:
Address:
Phone #:
Emergency Contact:
Authorized to Pick Up:
Attendance Data:
Time: from to
Days: Monday Tuesday Wednesday Thursday Friday
Start Date:
Medical Information:
Physician Name:
*
Physician Address:
Physician City:
Physician Phone #:
Dentist Name:
Dentist Address:
Dentist City:
Dentist Phone:
Hospital:
Insurance Provider:
Insurance Policy #:
Health Record:
Please inform us of any restrictions, chronic conditions, allergies or dietary restrictions that we should know about your child.
* A signed copy of required immunizations will be submitted by start date and will be updated as necessary.
* I certify that my child is enrolled in a regular medical program and has been examined by a doctor within the last 12 months.
* I understand that Apple Tree Children's Centers follow a State recommended health policy of which I have received a copy. I agree that 1. A child who appears ill upon arrival shall not be admitted to the Center. 2. When a child becomes ill at the Center, the parents shall be contacted and arrangements made for the child to be picked up imediately. This determination will be made by the center. 3. The Center may require a physician's statement prior to readmitting my child to the center following an illness. 4. At the time of registration, the parents shall authorize the child's physician to accept all calls from the child care director for emergency medical care.
 
Personal History: Please let us know about your child, ie: nickname, favorite relative or friends they may talk about; other centers or child care experiences; dressing, napping routines;how does he/she handle separation from parents; any special fears or problems; how does he/she communicate bathroom needs; etc. If your child shares living arrangements with more than one household, is there a determined schedule. Any other information that you feel is important for us to know in order to provide the best possible care for your child.
I hereby authorize Apple Tree Children's Center to take my child to the physician or facility as referred on the first page, for medical treatment in the event of an emergency in which neither parent nor emergency contact can be reached.
I hereby authorize any licensed physician or medical treatment center to treat my child in case of an emergency in which the above named physicain can not respond.
* I hereby authorize Apple Tree to trasport my child to or from school, on educational excursions, or on other center sponsored activities.
* I hereby authorize Apple Tree to include my child in supervised water activities.
* I give permission to Apple Tree to photograph my child and use the resulting photographs for any purpose Apple Tree deems proper (ie. publicity, advertising, etc.)
CHILD ABUSE POLICY: South Dakota Law (SDCL 26-10-10) mandates all licensed or registered child care providers to report any suspected incident of child abuse or neglect to the Dept. of Social Services or Law Enforcement. Reportable incidents include suspected abuse/neglect within this group care center.

REPORTING POLICY: Any staff member or volunteer who feels that a child in placement may have been abused or neglected at home or in the center is to immediately report her/his feelings to the director or to the individual who is designated as the Supervisor. After verbally reporting the incident to the director or her designee, the employee/volunteer is to document in wiring what he/she observed. This report is to include the date of the incident, time, those involved, and a statement of what was observed. This written report is to be given to the Director or the designee. Upon receiving the verbal report, the Director/designee is to immediately:

1. Report the incident to the Dept. of Social Services or Law Enforcement.
2. Incase of in-center child abuse, the staff member/volunteer will be dismissed immediately.
3. In the case of suspected in-house CA/N, determine if the children are safe pending the investigation. If a staff member/volunteer is involved, suspecsion may occur to protect children.
4. Cooperate with the Dept. of Social Services and/or Law Enforcement throughout the investigation.

Signed:
Date:
Review and Print enrollment form. Sign and hand in with immunization records by start date.
 
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