Enrollment Forms - Montrose - Bright Beginnings Preschool

Parent Initials ___________ School Initials___________
Bright
Beginnings
Preschool and Childcare, LLC
Enrollment Forms
120 N. Hillcrest Dr.
Montrose, CO 81401
970-252-3399
www.brightbeginningsmontrose.com
[email protected]
[email protected]
Bright Beginnings Preschool & Childcare, LLC
Enrollment Forms: Ages 0-5
(Revised 3/2013)
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Parent Initials ___________ School Initials___________
Deposit
A deposit is required for all families at the time of application. Such deposit is refundable if the child is not
admitted into care of Bright Beginnings Preschool & Childcare, LLC. If the child is admitted, the deposit may
be used to satisfy or partially satisfy a final bill for services or refunded if no payment is due at the end of the
relationship.
For parents who qualify for subsidy: The deposit will be the greater amount of one month's parent fee or
$50.
For parents who do not qualify for subsidy: The deposit will be the amount of half of the monthly fee’s
payable for the care of your child.
PLEASE NOTE: Applications will not be processed, childcare will not be provided nor will your opening be
considered saved until this deposit is paid in full.
I have paid a deposit of $________ and registration/materials fee of $________ for the ________ term to Bright
Beginnings Preschool & Childcare, LLC to provide care for the following
child:_______________________________
________________________________________
_________________________________________
Parent/Guardian’s Signature
Bright Beginnings Preschool & Childcare, LL Date
By Amber Gardner, Manager
Date
Bright Beginnings Preschool & Childcare, LLC
Enrollment Forms: Ages 0-5
(Revised 3/2013)
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Parent Initials ___________ School Initials___________
TERMS OF EDUCATIONAL AGREEMENT
Bright Beginnings Preschool & Childcare, LLC
(Agreement: Ages 0-5)
Start Date: _____/_____/_____
Child’s Full Name: _____________________________Parent/Guardian(s):____________________________
My child will attend Bright Beginnings Preschool & Childcare, LLC the following times:
Monday
________ to ________
Price per day:
$_________
Tuesday
________ to ________
Wednesday
Thursday
________ to ________
________ to ________
$_________
$__________
$_________
_____________
Friday
________ to ________
$_________
______________
Weekly Tuition x 4.25 = Monthly Tuition
Base Tuition: [Check One]
 Full Day (4.5 hours or more)
$30* per day = Includes breakfast, lunch, healthy snacks, and differentiated educational programs
*Children who are not potty-trained will have a $3 per day fee added to the monthly tuition. After the
child has completed one month without an accident, the $3 per day fee will no longer be assessed.
 Half Day (up to 4.5 hours)
$25* per day = Includes breakfast, lunch, healthy snacks, and differentiated educational programs
*Children who are not potty-trained will have a $3 per day fee added to the monthly tuition. After the
child has completed one month without an accident, the $3 per day fee will no longer be assessed.
 After School Care: 3:00-5:30
$15 per day = Includes healthy snack, homework help and small group tutoring.
Required Materials Fees: $50 per child, per term (Fall = June 1, Spring = Dec 1) Students only attending for
the summer months will pay a separate $50 fee.
Additional Tuition for Transportation Services: This includes transportation to and from school for those
children who are enrolled in K-6 in a RE-1J school. $10 per day transported, per month. For example,
transportation for 5 days per week is $50 per month. [Check One]
_________ days/week = ________/month
Or
_________Not Applicable
Overtime Fees: All children must be picked up by 5:30 p.m. or $1.00 per minute, per child late charge will be
assessed and is payable at retrieval of the child. All overtime duration will be calculated according to the clock
at Bright Beginnings Preschool and Childcare, LLC. Overtime that is prearranged (with a 24-hour notice) will
Bright Beginnings Preschool & Childcare, LLC
Enrollment Forms: Ages 0-5
(Revised 3/2013)
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Parent Initials ___________ School Initials___________
be $5 an hour per child, subject to availability. If such payment is not paid when due, this Agreement may be
terminated without further notice.
Late Payment Fee: A late charge of $5.00 per day shall be assessed to any payment amount not paid when
due. Bright Beginnings Preschool and Childcare, LLC may also terminate this Agreement and pursue other
remedies described herein or under the law.
Returned Check Fee: A $30.00 charge shall be applied to any returned checks. Cash shall be required upon
request of Bright Beginnings Preschool and Childcare, LLC.
Payment: All payments required under this Agreement are due in advance. This includes base tuition,
additional expenses, and materials fees. No credits or refunds are provided for late arrivals, early
departures, sickness or vacations. If payments are not made when due, Bright Beginnings Preschool and
Childcare, LLC, may terminate this Agreement without notice. Bright Beginnings Preschool and Childcare,
LLC, may pursue collection remedies and shall be due 1.5% per annum on all payments not made when due
plus shall be entitled to recover the cost of collection including reasonable attorney fees and costs. Please initial
one of the following.
________Monthly Discount: I agree to pay a monthly tuition of $_______________ due by the first day of each month. I
understand that if do not make payment by the first of the month, I will revert to the bi-monthly rate as
described below.
________ Bi-Monthly: I agree to pay a bi-monthly tuition of $______________ due the first and fifteenth of each month,
which includes a $20 monthly service fee.
Child Care Assistance Program (CCAP) For families who qualify for assistance, parent fees must be paid by
the first of the month. A child is allowed three absences per month under the county policy. After the third
absence, CCAP contracted rates must be paid for by the parent for each day the child is absent prior to the child
returning to school. If there are more than two unpaid absences, the child’s spot will be considered vacant and
may be filled immediately. In addition, if contracted for a full day, but choose to drop your child off later or
pick up earlier, resulting in less than five hours at school, you will be required to pay the difference for a half
day rate.
**All payments will be applied to Bright Beginnings charges prior to parental fees.
Release of Liability
You and your child, as well as your heirs, executors and assigns do hereby release Bright Beginnings Preschool
& Childcare, LLC owner and employees from any and all liability (except for gross negligence or intentional
wrongdoing) for any injury, illness to the child or third parties or other damage to personal property.
________________________________________
____________________________________________
Parent/Guardian’s Signature
Bright Beginnings Preschool & Childcare, LLC
By Amber Gardner, Manager
Date
Bright Beginnings Preschool & Childcare, LLC
Enrollment Forms: Ages 0-5
(Revised 3/2013)
4 of 15
Date
Parent Initials ___________ School Initials___________
General Provisions
The provisions of this Agreement shall be binding upon and shall inure to the benefit of the respective
successors and assigns of the parties. Following the effective date hereof, each party shall take such action and
execute such additional documentation that may be reasonably necessary or appropriate to effectuate the
objectives and provisions of this Agreement. Should any litigation be commenced between the parties to this
Agreement concerning this Agreement, or the rights and duties to either party in relation thereto, the party
prevailing in such litigation shall be entitled, in addition to such other relief that may be granted, to a reasonable
sum as and for its reasonable attorneys fees in such litigation which shall be determined by the court in such
litigation or in a separate action brought for that purpose. The representations and warranties set forth in this
Agreement shall survive the execution and performance of this Agreement. The headings in this Agreement are
for convenience only, confirm no rights or obligations in either party, and do not alter any terms of this
Agreement. This Agreement constitutes the entire agreement and understanding between the parties with
respect to the subject matter hereof and may not be modified or amended except in a writing signed by all of the
parties. The language of this Agreement shall be construed as a whole, according to its fair meaning and
intendment, and not strictly for or against any party, regardless of who drafted or was principally responsible for
drafting the Agreement or any specific term or condition thereof. This Agreement shall be deemed to have been
drafted by all parties, and no party shall urge otherwise. This Agreement shall be construed and enforced
pursuant to the laws of the State of Colorado. Should any provision of this Agreement be held illegal, such
illegality shall not invalidate the whole of this Agreement; instead, the Agreement shall be construed as if it did
not contain the illegal part, and the rights and obligations of the parties shall be construed and enforced
accordingly. All attachments to this Agreement are hereby attached hereto and incorporated herein by reference
as part of this Agreement (Attachments 1-7).
All Parent/Registrants shall provide a List of any Parent, Emergency Contact listed in Attachment 2, and any
individual authorized for Child pick-up listed in Attachment 3 who is required to register as a sex offender
pursuant to the provisions of the “Colorado Sex Offender Registration Act”, Article 22 of Title 16, C.R.S.
(“Act”) The List shall include the name, address, and telephone number of the Offender. Please also provide
the specific conviction that led to requirement to register as a sex offender under the Act, and the names and
contact information for any Community Supervision Team Members, Providers for sex offender services,
Probation Officers, and any other authority contracted for the facilitation of the Offender’s compliance with the
Act. Bright Beginnings reserves the right to contact any person, authorized agent, or entity provided in the List
for information including, but not limited to, the Offender’s charge, plea, sentence, probation period,
registration requirements, registration status, and any restrictions for access to safety zones. Based on the
information obtained, Bright Beginnings will take appropriate action to maintain the safety and security of
students. A Registrant’s failure to provide the names of any Offenders as required in this Section shall be
grounds for termination as set forth in this Agreement.
I, the undersigned, being the parent or legal guardian of the above named child, enroll my child in Bright
Beginnings Preschool & Childcare, LLC. I have read the Agreement, attachments and Policies and agree
to adhere to all statements therein. I understand that I am key in the healthy development of my child,
and therefore commit to maintaining a healthy working relationship with Bright Beginnings Preschool &
Childcare, LLC.
____________________________________________
____________________________________________________
Parent/Guardian’s Signature
Bright Beginnings Preschool & Childcare, LLC
By Amber Gardner, Manager
Date
Bright Beginnings Preschool & Childcare, LLC
Enrollment Forms: Ages 0-5
(Revised 3/2013)
5 of 15
Date
Parent Initials ___________ School Initials___________
Attachment 1: Registration
Please fill out ALL information completely or answer N/A (not applicable). Thank you.
_______________________________________________________________________________________________________________________
1st Parent Last Name
First Name
Relationship
_______________________________________________________________________________________________________________________
Address
City
State
Zip
_______________________________________________________________________________________________________________________
Cell Phone
Other phone
E-Mail Address
_______________________________________________________________________________________________________________________
Place of Employment
_______________________________________________________________________________________________________________________
Work Address
City
State
Zip
_______________________________________________________________________________________________________________________
Work Phone Number
Work Hours
Title
*Copy of Driver’s License?
(Y)
(N)
_______________________________________________________________________________________________________________________
2nd Parent’s Last Name
First Name
Relationship
_______________________________________________________________________________________________________________________
Address
City
State
Zip
_______________________________________________________________________________________________________________________
Cell Phone
Other phone
_______________________________________________________________________________________________________________________
Place of Employment
_______________________________________________________________________________________________________________________
Work Address
City
State
Zip
_______________________________________________________________________________________________________________________
Work Phone Number
Work Hours
Title
email address
*Copy of Driver’s License?
(Y)
(N)
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Enrollment Forms: Ages 0-5
(Revised 3/2013)
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Please fill out ALL information completely or answer N/A (not applicable). Thank you.
_______________________________________________________________________________________________________________________
Child’s Last Name
First Name
Age
Gender
_______________________________________________________________________________________________________________________
Address (if different from parent/guardian)
Birthdate
Any known allergies?
(Y)
(N)
Comments__________________________________________________________________________
Medication being taken?
(Y)
(N)
Comments__________________________________________________________________________
Special Diet Required?
(Y)
(N)
Comments__________________________________________________________________________
Any chronic health condition?
(Y)
(N)
Comments__________________________________________________________________
*General Health Appraisal Form completed and received? (Y)
(N)
Date______________
*Immunization Record completed and received?
(Y)
(N)
Date______________
(Y)
(N)
Date______________
If not, is the immunization waiver on file?
Pediatric Physician & Dentist Information
_______________________________________________________________________________________________________________________
Dr. Last Name
First Name
Phone Number
_______________________________________________________________________________________________________________________
Facility Name/Address
City
State
Zip
_______________________________________________________________________________________________________________________
Dentist Last Name
First Name
Phone Number
_______________________________________________________________________________________________________________________
Facility Name/Address
City
State
Zip
_______________________________________________________________________________________________________________________
Preferred Hospital Name
Address
Phone Number
______________________________________________________________________________________________________________________
Insurance Carrier
Policy #
Bright Beginnings Preschool & Childcare, LLC
Enrollment Forms: Ages 0-5
(Revised 3/2013)
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Attachment 2
Authorization for Emergency Medical Care/Treatment of a Minor
Child’s Information
In the event of an emergency requiring a physician’s care, do you wish for us to call your family physician?
If yes, please provide the following:
Yes (
) No (
)
____________________________________________________________________________________________________________
Physician’s Name
Facility
Phone Number
I (we), __________________________________________ and ______________________________________________________,
do hereby state that I am (we are) parent(s) or legal guardian(s) of _____________________________________________________,
who resides with me (us) at ____________________________________________________________________________________ .
Address
City
State
Zip
I (we),______________________________________________________________________________________________________
authorize for emergency purposes only, a designated employee of Bright Beginnings Preschool & Childcare, LLC to transport the
above minor by ambulance, and consent to any necessary examination, anesthetic, medical advice and/or medical treatment from a
physician or surgeon licensed to practice medicine in the State of Colorado. Any expenses incurred will be the responsibility of the
parent(s)/legal guardian(s).
____________________________________________________________________________________________________________
Last Tetanus/Diptheria Booster
Allergies to drugs or foods (please indicate)
____________________________________________________________________________________________________________
Please list any special medications or pertinent information
AUTHORIZATION
____________________________________________________________________________________________________________
Parent(s)/Legal Guardian(s) Signature(s)
date
EMERGENCY CONTACTS IN ORDER OF PREFERENCE INCLUDING PARENTS/LEGAL GUARDIANS
__________________________________________________________________________________________________
Name
Relationship
Daytime Phone Number
__________________________________________________________________________________________________
Name
Relationship
Daytime Phone Number
__________________________________________________________________________________________________
Name
Relationship
Daytime Phone Number
__________________________________________________________________________________________________
Name
Relationship
Daytime Phone Number
Bright Beginnings Preschool & Childcare, LLC
Enrollment Forms: Ages 0-5
(Revised 3/2013)
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Parent Initials ___________ School Initials___________
Attachment 3
AUTHORIZATION FOR CHILD PICK-UP
The names of at least one or two individuals, in addition to parent(s)/guardian(s), who are authorized to pick up your child, must be on file in the
center’s office. If anyone else will be picking up your child, a “password” will be required (see below) and is considered an “unusual pickup
authorization”. The center shall not release a child to anyone who is not authorized in writing to pick up.
CHILD INFORMATION
__________________________________________________________________________________________________________________
Child’s Name
PASSWORD FOR UNUSUAL PICKUP AUTHORIZATION
______________________________________________________________________________
This password should be kept confidential. Only the parent(s)/guardian(s) and Bright Beginnings Preschool & Childcare, LLC Director (or
authorized substitute) will know it. The password is used as a means of positively identifying the parent/guardian if they call the center to authorize
an unusual pickup. The pickup person does not need to know the password. They MUST have a photo ID however.
AUTHORIZED FOR PICKUP
MOTHER
(Y)
(N)
FATHER
(Y)
(N)
__________________________________________________________________________________________________________________
Name
Relationship
__________________________________________________________________________________________________________________
Address
__________________________________________________________________________________________________________________
Home Phone
Work Phone
Cell Phone
AUTHORIZED FOR PICKUP
__________________________________________________________________________________________________________________
Name
Relationship
__________________________________________________________________________________________________________________
Address
__________________________________________________________________________________________________________________
Home Phone
Work Phone
Cell Phone
AUTHORIZED FOR PICKUP
__________________________________________________________________________________________________________________
Name
Relationship
__________________________________________________________________________________________________________________
Address
__________________________________________________________________________________________________________________
Home Phone
Work Phone
Cell Phone
AFTER HOURS - If a child has not been picked up by closing time, it is the responsibility of the Director (or authorized substitute) to attempt to contact the parents
and every authorized pick up person listed on this form. If no contact can be made to arrange a pick up, legal authorities must be notified. If these authorities are also
unable to make a contact, the child must be cared for as directed by these authorities. The staff is not permitted to remove the child from the center and continue to care
in their home or at any other location.
______________________________________________________________________________________________________________________
Signature (Parent or Legal Guardian)
Date
Bright Beginnings Preschool & Childcare, LLC
Enrollment Forms: Ages 0-5
(Revised 3/2013)
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Parent Initials ___________ School Initials___________
Attachment 4
Consent and Release Forms
Child’s Name_______________________________________ DOB_________________
Photography Permission Form
On various occasions, your child may be photographed while at Bright Beginnings Preschool & Childcare, LLC. These
photographs may be used by Bright Beginnings Preschool & Childcare, LLC in program planning, crafts, weekly newsletters
and/or public relations. They also may be used in various types of advertising, or by public television, newspapers, magazines,
electronic or digital communication. For this reason, we request that each parent sign the following release:
Parent Consent
I hereby, give, or do not give, Bright Beginnings Preschool & Childcare, LLC, the absolute right and permission to copyright
and/or publish, or use photographic portraits or pictures of my child, or reproductions thereof in color or otherwise, made through any
media for art, advertising, trade electronic or digital communication or any other lawful purpose whatsoever. These pictures may be
used in conjunction with his/her own (or fictitious) name.
[
]
No, I do not grant full permission.
[
]
Yes, I do grant full permission.
[
]
Yes, I grant permission for internal use only. I understand my child’s picture will only be used for craft activities.
____________________________________
Parent/Guardian’s Signature
__________________
Date
--------------------------------------------------------------------------------------------------------------------------------------Field Trip Permission Form
PERMISSION FOR WALKING FIELD TRIPS:
I give permission for my child to take part in any walking field trip with class/group around the neighborhood immediately
surrounding the Bright Beginnings Preschool & Childcare, LLC facility.
____________________________________
Parent/Guardian’s Signature
__________________
Date
PERMISSION FOR SCHOOL TRANSPORT:
I give permission for my child to be picked up from public school by Bright Beginnings Preschool & Childcare, LLC transport
vehicle and authorized staff member.
____________________________________
Parent/Guardian’s Signature
__________________
Date
Bright Beginnings Preschool & Childcare, LLC
Enrollment Forms: Ages 0-5
(Revised 3/2013)
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Parent Initials ___________ School Initials___________
Sunscreen Permission Form
As the parent or guardian of the above child, I recognize that too much sunlight may increase my child’s risk for skin cancer later in
life. Therefore, I give my permission for the staff at Bright Beginnings Preschool & Childcare, LLC to apply Rocky Mountain
Sunscreen SPF 30 to my child, as specified below, when he or she will be playing outside, especially during the months of April
through September.
I further understand that sunscreen may be applied to exposed skin, including but not limited to the face, tops of ears, nose, bare
shoulders, arms, and legs.
INGREDIENTS FOUND IN SPF 15, 30, 45
Aloe Barbadensis Leaf Juice, Carbomer, Cetyl Alcohol, Cholecalciferol (Vitamin D), DEA-Cetyl, Phosphate, DMDM Hydantoin
(and) Iodopropynyl Butylcarbamate, Hydrogenated Polybutene, Retinyl, Palmitate (Vitamin A), Stearic Acid, Tocopheryl Acetate
(Vitamin E), Triethanolamine, Water.
ACTIVE INGREDIENTS IN SPF 30
Ethylhexyl p-Methoxycinnamate (Octinoxate), 2-Ethylhexyl Salicylate (Octisalate) Oxybenzone,
Homosalate
ROCKY MOUNTAIN SUNSCREEN IS PABA-FREE, WATERPROOF, HYPOALLERGENIC, FRAGRANCE-FREE, NONGREASY, MOISTURIZING, AND ALOE-BASED.
I have checked all applicable information regarding the type and use of sunscreen for my child:
____I have consulted with my child’s physician, and do not know of any allergies or allergic reactions my
child may have to Rocky Mountain Sunscreen SPF 30.
____Staff may apply Rocky Mountain Sunscreen SPF 30, certified by the AMC Cancer Research Center
as a top-quality sun protection product, to my child as described above.
_____NO. FOR MEDICAL REASONS, DO NOT APPLY SUNSCREEN TO MY CHILD UNDER ANY CIRCUMSTANCES.
____________________________________
Parent/Guardian’s Signature
__________________
Date
Bright Beginnings Preschool & Childcare, LLC
Enrollment Forms: Ages 0-5
(Revised 3/2013)
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Attachment 5: CHILD INFORMATION FORM
*This form will remain in the child’s classroom with their teacher.
Name: _____________________________________ Age:________ Date of Birth: _____/_____/_____
Parent Name:_______________________________________
Phone Number ___________________
Parent Name:_______________________________________
Phone Number ___________________
Allergies:_______________________________________________________________________________
Medication (prescription and OTC): _________________________________________________________
Special Diet Needs: ______________________________________________________________________
Favorite Snacks: _________________________________________________________________________
Does your child feed him/herself?
[ ] with a spoon
[ yes ] [ no ] If yes, independently or with assistance? __________
[ ] with a fork
[ ] with hands
Napping Routine: ________________________________________________________________________
My child loves:___________________________________________________________________________
My child does not like:_____________________________________________________________________
My child is soothed by:_____________________________________________________________________
My child gets upset when: __________________________________________________________________
Current language abilities: Primary Language ____________
[ ] words [ ] phrases [ ] sentences
Uses any sign language [ yes]
[ no ]
[ ] conversant
My child [ is ] [ is not ] toilet trained.
If yes, does your child request to go to the bathroom independently, or need reminded?___________________
Special diapering/bathroom instructions ________________________________________________________
Previous experience in childcare/preschool______________________________________________________
Does your child have an IEP/IFSP that we could support? __________________________________________
Additional information you think would be helpful for us to know about your child:
_________________________________________________________________________________________
_________________________________________________________________________________________
_______________________________________
Parent/Guardian Signature
date
Bright Beginnings Preschool & Childcare, LLC
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(Revised 3/2013)
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Attachment 6
Bright Beginnings Preschool & Childcare, LLC
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Bright Beginnings Preschool & Childcare, LLC
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Bright Beginnings Preschool & Childcare, LLC
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