Enrollment Agreement Step 1 of 812%To ensure a streamlined enrollment process, we kindly request that you prepare the following documents for upload (scanned pdf or images) prior to commencing the enrollment form: - Physician's Care Instructions pertaining to any illnesses and/or life-threatening allergies. - The child's Immunization Records. Should you wish to pause and resume your application at a later time, the 'Save and Continue' feature allows you to do so. Upon activation, this feature will generate a unique link to your application, with an option to dispatch this link directly to your email address for safekeeping. We strongly advise saving this link for future reference. Additionally, for your convenience, you may also choose to download and print the enrollment form or opt to pick up a physical copy at the center. Download at EnrollmentChild's InformationChild's first name(Required)Child's middle name(Required)Child's last name(Required)Child’s nickname(Required)Age(Required)Sex(Required)Child's primary language(Required)Parent/guardian/sponsor primary language(Required)Child’s home address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Does your child attend school?(Required)YesNoSchool name(Required)Grade(Required)School phone(Required)School address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Drop off time(Required)Pick up time(Required)Family InformationList family members & pets your child lives with – include first names, relation and ages of siblings(Required)Parent/guardian/sponsor(Required)Relationship to child(Required)Home phone(Required)Cell phone(Required)Home address if different from above Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home email(Required) Work email(Required) Work phone(Required)Employer(Required)Employer address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Work hours(Required)2nd parent/guardian/sponsor(Required)Relationship to child(Required)Home phone(Required)Cell phone(Required)Home address if different from above Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home email(Required) Work email(Required) Work phone(Required)Employer(Required)Employer address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Work hours(Required)Child Emergency Contact and Release Information (do not include parents/guardians/sponsors)Please notify the center if an Emergency Release Contact will pick up your child on a given day. [For the safety of your child, we request that all authorized pick up persons with whom staff is not familiar provide a photo ID at the time of pick up.] Please type N/A if not applicable.Person #1(Required)Relationship to child(Required)Home phone(Required)Cell phone(Required)Home address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home email(Required) Work email(Required) Work Phone(Required)Employer(Required)Employer address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Work hours(Required)Person #2(Required)Relationship to child(Required)Home phone(Required)Cell phone(Required)Home address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home email(Required) Work email(Required) Work Phone(Required)EmployerEmployer address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Work hours(Required)Person #3(Required)Relationship to child(Required)Home phone(Required)Cell phone(Required)Home address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home email(Required) Work email(Required) Work Phone(Required)EmployerEmployer address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Work hours(Required)The persons designated in this section will be contacted by us if you cannot be reached in the event of a medical or other emergency. Our staff will only release your child to you or to those persons listed above. If you want a person who is not identified above to pick up your child, you must notify our staff in advance, in writing. Your child will not be released without prior authorization.Parent initial(Required)Today's Date(Required) MM slash DD slash YYYY Medical InformationChild’s name(Required)Birth date(Required) MM slash DD slash YYYY Height(Required)Weight(Required)Hair color(Required)Eye color(Required)Distinguishing marksChild’s Medical & Developmental HistoryDoes your child have any special medical conditions?(Required) No YesExplain(Required)Does your child have any chronic illnesses?(Required) No YesExplain(Required)Please list a brief history of your child’s serious injuries and hospitalizations.(Required)Does your child have diabetes?(Required) No YesIf yes, please attach care instructions from your physician(Required) Drop files here or Select filesMax. file size: 25 MB.Does your child have asthma?(Required) No YesIf yes, please attach care instructions from your physician(Required) Drop files here or Select filesMax. file size: 25 MB.Will medication be administered regularly?(Required) No YesIf yes, please attach care instructions from your physician(Required) Drop files here or Select filesMax. file size: 25 MB.Does your child have any special dietary needs?(Required) No YesExplain(Required)Is your child able to fully participate in all activities?(Required) Yes NoExplain(Required)Does your child have any physical restrictions?(Required) No YesExplain(Required)Does your child function at the level of other children in his/her age group?(Required) Yes NoExplain(Required)Is your child able to walk?(Required) Yes NoExplain(Required)Can your child communicate his/her needs?(Required) Yes NoExplain(Required)Does your child need assistance at meal time?(Required) No YesExplain(Required)Does your child rest during the day?(Required) Yes NoIs your child toilet trained?(Required) Yes NoDoes your child use any special equipment, such as breathing machine, wheelchair, hearing aid, braces, glasses etc.?(Required) No YesExplain(Required)Does your child require one-to-one care/supervision on a regular basis for a significant period of time?(Required) No YesExplain(Required)Does your child require any accommodations or modifications to fully and equally enjoy and participate in a group care setting?(Required) No YesExplain(Required)Illness History (please check all that apply)(Required) Vision problems Nosebleeds Seizures Hearing problems Skin rashes Mouth sores Constipation Sore throats Fainting Diarrhea Ear infections Persistent cough Asthma/breathing problems Urinary tract infections Other None of the abovePlease attach care instructions from your physician for any of these illnesses. Drop files here or Select filesMax. file size: 25 MB.Disease History (please check all that apply and add the date)(Required) Chicken Pox (Varicella) Bronchiolitis Botulism Measles Rubeola Pneumonia Haemophilus Influenza Rubella (German Measles) Pertussis (Whooping cough) Meningococcal Infection Mumps Tetanus Rabies Scarlet Fever Diphtheria Bacterial Meningitis None of the aboveName and date of diseaseAllergies (please list)Please type none if no allergies.Medication AllergiesReactionFood AllergiesReactionBee Stings AllergiesReactionRespiratory AllergiesReactionOther AllergiesReactionAre any of these allergies life-threatening? No YesPlease attach care instructions from your physician for any life-threatening allergies. Drop files here or Select filesMax. file size: 256 MB.Parent initial(Required)Date(Required) MM slash DD slash YYYY Medical Information (continued)Childs name(Required)Birth date(Required)Please type N/A if not applicablePrimary physician’s name(Required)Primary physician’s practice name(Required)Phone(Required)Physician’s practice address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Preferred hospital/clinic for emergency care(Required)City(Required)State(Required)Dentist’s name(Required)Dentist’s practice name(Required)Phone(Required)Dentist’s practice address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Child’s Insurance ProviderPlease type N/A if not applicableChild’s health insurance provider name(Required)Policy number(Required)Secondary health insurance provider name(Required)Policy number(Required)Child’s Immunization History (please attach a copy of your child’s immunization records)Tennessee requirements can found on http://www.immunize.org/states/immunization records(Required) Drop files here or Select filesMax. file size: 256 MB.Additional Medical PoliciesPrior to enrollment, I must provide the center with updated medical and immunization information for my child. This information is to be kept current and updated in accordance with state child care regulations.(Required)InitialI agree to provide information to the child care center about my child’s conditions, illnesses, allergies or other needs.(Required)InitialIf my child becomes ill with a reportable contagious disease, I understand that he/she will not be able to return until I bring in a physician’s note stating that he/she is no longer contagious.(Required)InitialIf my child becomes ill during his/her time at the child care center, the staff will contact me to pick up my child. I will arrange for pick up as soon as possible and no later than 2 hours after being contacted. If I cannot be reached, the staff will contact those listed in the Child Emergency Contact and Release.(Required)InitialEmergency Medical Authorization & ConsentIn case of a medical emergency, the staff will attempt to contact me, those listed in the Child Emergency Contact and Release, and lastly my physician.(Required)InitialIn case of a medical emergency, I agree that my child may receive first aid and/or CPR.(Required)InitialIn case of a medical emergency, I permit the transportation of my child to a local hospital or other urgent care facility, if necessary, by paramedics or other emergency personnel.(Required)InitialIn case of a medical emergency, I will be responsible for the emergency medical expenses.(Required)InitialIn case of an accidental ingestion of a poisonous substance, I consent to my child being treated as directed by the Poison Control Center.(Required)InitialI give my permission to this center to apply the following to my child.. Please check which products you will permit.(Required) Sunscreen insect repellantInitial(Required)I understand that I must supply my own sunscreen and/or insect repellant with a valid expiration date, and it will be labeled with my child’s name.(Required)InitialParent initial(Required)Date(Required) MM slash DD slash YYYY Rate Agreement and ContractChilds name(Required)Birth date(Required)Hours of OperationRegular operating hours are 6:00 am-5:30pm except closings for various holidays, and inclement weather as described in the Family Handbook. Please consult the current calendar for holidays. There is no reduction in tuition as a result of center closures.The procedure to notify families should severe weather or other conditions prevent the program from opening on time or at all will be announced on our website, and via automated texts/email notifications. If it becomes necessary to close early, we will contact you or someone listed in the Emergency Contact and Release, and it will be your responsibility to arrange for your child’s early pick up.Scheduled AttendanceThe days and hours that I wish to contract for childcare are as follows: Please type N/A if not applicableMondayStart timeAM/PMEnd timeCommentsTuesdayStart timeAM/PMEnd timeCommentsWednesdayStart timeAM/PMEnd timeCommentsThursdayStart timeAM/PMEnd timeCommentsFridayStart timeAM/PMEnd timeCommentsI would prefer to make tuition payments on a ___ basis(Required) weekly bi-weekly monthlyOther AgreementsAny arrangement/employment between me and staff of this center (i.e., babysitting), outside of the programs and services offered by this center, is an individual endeavor and private matter not connected to or sanctioned by this center. This center shall remain harmless from any such arrangement.(Required)InitialMedia ReleaseOccasionally, photos will be taken of the children at the center for use within the center or on our website and/or newsletters. Please indicate that you authorize the use and reproduction of photographs of your child in conjunction with the program.(Required)InitialParent initial(Required)Date(Required) MM slash DD slash YYYY Other Agreements (continued)Child’s name(Required)Birth date(Required)Walking ExcursionsI give my permission for my child to participate in supervised walking excursions near and around the center.(Required)InitialHandbook AcknowledgementI understand and agree that it is my responsibility to read and familiarize myself with policies and procedures outlined in the Family Handbook and agree to abide by them.(Required)InitialI understand that it is my responsibility to go directly to management with any questions I may have regarding the policies and procedures and information contained in this Enrollment Agreement.(Required)InitialInformation contained in the Family Handbook may be subject to change.(Required)InitialContract ApprovalI certify that I have read, understand, and accept all of the terms and conditions described in this Enrollment Agreement.Primary Parent/Guardian/Sponsor Signature(Required)Date(Required) MM slash DD slash YYYY I'd like to receive an email copy of this form(Required) Yes NoSend me the form to this email address(Required)