Registration Form

Registration Form
2014-2015
Monday/Wednesday or Tuesday/Thursday 9:00am – 2:00pm
Walking – 24 months
25 months – 36 months
37 months – 48 months
49 months – 5 yrs
Child’s Full Name____________________________________________________________________ Age______________________
Child’s Sex____________ Birth Date ________/________/________ Preferred Name_______________________________________
Parents/Guardians_______________________________________ Address ______________________________________________
City______________________________________________________ State ______________ Zip___________________________
Home Phone _________________________Mom’s Cell __________________________ Dad’s Cell___________________________
E-Mail_______________________________________________________________________________________________________
Mom’s Occupation ______________________________________Work Phone ___________________________________________
Dad’s Occupation_______________________________________ Work Phone____________________________________________
Emergency Contacts:
Name _____________________________________Relationship to Child____________________ Phone_______________________
Name _____________________________________Relationship to Child____________________ Phone_______________________
Child’s Doctor________________________________ Phone________________________ Hospital Choice _____________________
In the event of an emergency, may we take your child to the doctor you have designated if none of the above can be reached?
_______________________ May we take your child to the hospital? ____________________________________________________
Does your child have special needs regarding health or allergies? ___________ if yes, please list ______________________________
____________________________________________________________________________________________________________
List Characteristics of your child that you think would be helpful to care-givers ____________________________________________
____________________________________________________________________________________________________________
Stepping Stones PDO * Revive Church * [email protected]
7198 Nolensville Rd. Nolensville, TN 37135 * (615) 776-5057 or (615) 426-1706
Additional Emergency Contacts & Persons to whom we may release your child. (Optional)
Photo I.D. will be required for alternate pickup persons
Authorized to Pick-up Child
Relationship to Child
Name
Phone
Please make checks payable to Stepping Stones PDO.
The Non-Refundable Summer $85 / Fall $100 Registration Fee is payable at the time a completed registration
is submitted.
Summer Monthly Tuition: $185 (2-day program)
Fall Monthly Tuition: $175 (2-day program)
Conditions of Enrollment
th
All tuition must be paid monthly by the 10 of each month in order to avoid a late fee, unless alternative arrangements have been
th
made with the office. If not received by the 10 there will be a $10 late fee.
All children must be able to adjust to separation from a parent/guardian and follow basic directives given by a teacher.
Any irreconcilable differences between parents and the program guidelines/restrictions may result in relinquishment of a position
within the program.
_____________________________________________________________
____________________________________
Signature of parent
Date
For Office Use Only: Date Received_______________________ Check #__________________
Amount___________________ Class_________________ Date of tour____________________
Sate Summary Received__________________Comments_______________________________
Stepping Stones PDO * Revive Church * [email protected]
7198 Nolensville Rd. Nolensville, TN 37135 * (615) 776-5057 or (615) 426-1706
Liability Release 2014-2015
RELEASE OF ALL CLAIMS – FILLED OUT BY PARENTS OR GUARDIAN
On behalf of my child participant if said child is not 21 years of age or older) do hereby release, forever discharge and
agree to hold harmless Tusculum Hills Baptist Church and the directors thereof from any and all liability, claims or
demands for personal injury, sickness , as well as property damage and expenses, of any nature whatsoever which may
be incurred by the undersigned and the child-participant that occur while said child is participating in the above
described camp and activities. Furthermore, we (I) [and on behalf of our (my) child-participant if under the age of 21
years] hereby assume all risk of personal injury, sickness, damage and expense as a result of participation in recreation
and work activities involved therein.
Further, authorization and permission is given to said church to furnish any necessary food and lodging for this
participant. The undersigned further hereby agree to hold harmless and indemnify said church, its directors, employees
and agents, for any liability sustained by said church as the result of the negligent, willful or intentional acts of said
participant, including expenses incurred attendant thereto. (If the participant has not attained the age of 21 years): We
(I) are (am) the parent(s) or legal guardian(s) of this participant, and hereby grant our (my) permission for him/her to
participate fully in said trip, and hereby give our (my) permission to take said participant to a doctor or hospital and
hereby authorize medical treatment, and assume the responsibility of all medical bills, if any.
Further, should it be necessary for the participant to return home due to medical reasons, disciplinary action or
otherwise, we (I) hereby assume all transportation costs.
Name of Participant: ____________________________________________________________
Parent(s)/Guardian(s) Names: ____________________________________________________
Phone Number(s): (______) __________________ (H) (______) ____________________ (W)
In case of emergency, contact: _________________________ (_____) ____________________
Insurance Company: ____________________________________________________________
Policy number: ________________________________________________________________
Physician’s Name: ________________________ Phone # (______) _______________________
Any Allergies? ________ if yes, please list: __________________________________________
Are you presently on medication? _________ if yes, please list: _________________________
_____________________________________________________________________________
Please list any medical conditions that we need to be aware of: _________________________
_____________________________________________________________________________
Father/Legal Guardian_____________________________________ Date_________________
Mother/Legal Guardian____________________________________ Date_________________
Stepping Stones PDO * Revive Church * [email protected]
7198 Nolensville Rd. Nolensville, TN 37135 * (615) 776-5057 or (615) 426-1706
Please read each section. Sign and date where applicable. Your registration will not be valid until these forms are signed.
Financial Obligations
In the event a student has registered and has been accepted, but fails to pay the first month’s tuition on the first day of school, the
student’s registration will become void and the opening in the class filled with the first available applicant on the waiting list.
The registration fee cannot be refunded. All withdraws must be made in writing to the office and shall be effective when such notice
is delivered to the school.
Tuition is calculated on the basis of the entire school year; therefore, no reductions can be made for vacations or school holidays.
Reductions cannot be made for tuition for absence during the school year. If a student leaves the school for any reason during the
school year, or enters after the school year has begun, charges are pro-rated according to the actual number of days enrolled.
Tuition must be turned in to the teacher on the first school day of each month. A late fee of $10 will be added to your child’s tuition
th
after the 10 day of each month. If your child is absent during the first week, you must make arrangements with the director to
avoid late fees.
I/We agree to uphold the financial obligations as stated above. We also agree to follow the guidelines and regulations as stated in
the Student/Parent Handbook.
________________________________________________________
Signature
________________________
Date
Permission to Participate in School Activities & to Receive Emergency Medical Care
I hereby grant permission for my child to use all of the play equipment and participate in all of the activities of the school.
I hereby grant permission for the teacher or director to take whatever steps may be necessary to obtain emergency medical care if
warranted. These steps may include, but are not limited to, the following:
1. Attempt to contact a parent or guardian.
2. Attempt to contact the child’s physician.
3. Attempt to contact the child’s parent or guardian through any of the persons listed on any part
of the application.
4. If we are unable to contact you or your child’s physician. We will do any or all of the following:
a. Call another physician.
b. Call an ambulance.
c. Have the child taken to an emergency hospital in the company of a staff member.
Signature of Father/Legal Guardian________________________________ Date____________
Signature of Mother/Legal Guardian_______________________________ Date____________
Medical Release
Stepping Stones PDO * Revive Church * [email protected]
7198 Nolensville Rd. Nolensville, TN 37135 * (615) 776-5057 or (615) 426-1706
I, ___________________________________, hereby give permission for Stepping Stones Parents Day Out to
call a physician, secure necessary medical care, including the administration of anesthesia if surgery is advised
by a physician and to otherwise act on my behalf when I cannot be reached and/or when delay would be
dangerous, in order to protect my child, in case of illness or accident.
_____________________________________________
Parent Signature
Date
__________________________________________
Parent Signature
Date
Emergency Medication Authorization
In the event that your child should need to receive medication in an emergency situation please provide the
following information along with your written consent.
Student’s name: ____________________________________________________________________________
Medication to be given: _____________________________ Dosage to be given: ________________________
Any potential side effects: ____________________________________________________________________
Doctor’s name and phone number: _____________________________________________________________
I hereby give permission for Stepping Stones staff to administer the stated medication and dosages as listed
above.
I hereby agree to uphold the Illness Policy as stated in the Parent Handbook.
______________________________________________
Signature of Parent/Guardian
____________________________________
Date
Photo Waiver
Periodically, Stepping Stones would like to use photos of the children for our Web Pages, Blog, Slide
Presentations or Printed Materials.
Please sign the waiver and indicate if you do or do not authorize us to use your child’s image.
I hereby grant/do not grant Stepping Stones Parent’s Day Out & Tusculum Hills Baptist Church full rights to
Circle one
Copyright, exhibit, and publish in any medium including, but not limited to, promotion, advertising, or Internet
photographs taken by the Stepping Stones Parent’s Day Out & Tusculum Hills Baptist Church of my child
__________________________________________________________________________________________
(Name of child being photographed)
__________________________________________________________________________________________
Parent/Guardian Signature
Stepping Stones PDO * Revive Church * [email protected]
7198 Nolensville Rd. Nolensville, TN 37135 * (615) 776-5057 or (615) 426-1706
Stepping Stones PDO * Revive Church * [email protected]
7198 Nolensville Rd. Nolensville, TN 37135 * (615) 776-5057 or (615) 426-1706
*All information is required and must be completed by the parent(s) or legal custodian(s)/ if unknown use N/A or non until it can be added later and initialed.*
Child’s Information:
Child’s birth date__________________________________________________________ Date of Admission ____________________
Full name of child_______________________________________________ Preferred name _________________________________
Parent’s Information:
Mother’s Name________________________________________ Father’s Name___________________________________________
Address: ______________________________________________ Address: ______________________________________________
_______________________________________________
______________________________________________
Phones: Home___________________ Work _________________ Home_____________________ Work _____________________
Where Employed: _______________________ Hours________
Where Employed_______________________ Hours__________
Misc. Information_____________________________________________________________________________________________
Custodial Parent if divorced________________________________ (provide the child care a copy of the custody order) Y____ N____
Persons authorized to pick up and transport the child other than parent or custodian: [give full name and phone number of the person to
whom the child may be released. They must be listed below to insure the child’s safety. A phone call is not acceptable permission of the parent(s) or custodians(s).
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Emergency Information:
1) Name of person(s) and the phone numbers, other than the child care staff, authorized to act for parent in an emergency
____________________________________________________________________________________________________________
Address________________________________ Home Phone________________________ Work Phone________________________
Employer_______________________________________________ Work Hours __________________________________________
2) Name of person(s) and the phone numbers, other than the child care staff, authorized to act for parent in an emergency
____________________________________________________________________________________________________________
Address________________________________ Home Phone________________________ Work Phone________________________
Employer_______________________________________________ Work Hours __________________________________________
Name of Physician: ________________________________ Office Phone______________ Home___________
Medical Association and Address_________________________________________________________________________________
____________________________________________________________________________________________________________
Special written doctor’s instructions for care or medical treatment given the child are______________________________________
To whom any medical training and/or instruction and permission given__________________________________________________
Any food, environmental, and/or medical allergies___________________________________________________________________
Other children and members of the family:
Birth Date
School/Work
___________________________________
________________________
____________________________________
____________________________________
________________________
____________________________________
____________________________________
________________________
____________________________________
____________________________________
________________________
____________________________________
____________________________________
________________________
____________________________________
Stepping Stones PDO * Revive Church * [email protected]
7198 Nolensville Rd. Nolensville, TN 37135 * (615) 776-5057 or (615) 426-1706
Developmental Health History
(Infants-young children)
Eating Habits:
At what time does the child eat breakfast? _________________ Dinner/lunch? _______________ Dinner/Supper?
_______________
Between mean snack? ______________________________ feeds themselves? ___________________________________________
What is the child’s general attitude toward eating? __________________________________________________________________
Does the child refuse to eat? __________________ How is this handled and by whom? _____________________________________
____________________________________________________________________________________________________________
The child’s favorite foods: ______________________________________________________________________________________
[If your child is an infant, use the space below for information about the formula, bottle schedule, etc. The parent must work closely
with the child care facility while introducing new baby foods and table foods to the child.]
Potty Training:
Is your child potty trained? ________________________ Does your child need assistance using the bathroom? ________________
Physical History:
What health problem has your child had in the past? _________________________________________________________________
____________________________________________________________________________________________________________
What health problems does your child have now? ___________________________________________________________________
____________________________________________________________________________________________________________
Other than what you listed above:
Does your child have any allergies? If so, to what? ___________________________________________________________________
How severe? _________________________________________________________________________________________________
Does your child take any medication regularly? If so, what and when? ___________________________________________________
Has your child ever been hospitalized? If so, when and why? __________________________________________________________
____________________________________________________________________________________________________________
Does your child have any recurring chronic illness or health problems? Please list:
______ Asthma
______Cerebral palsy
______Developmental delay
______ Seizure disorder
______ Diabetes
______Frequent earaches
______Hemophilia
______ Other
If medically diagnosed, what is the name of the doctor who diagnosed the illness or health problem? _________________________
____________________________________________________________________________________________________________
Do you have any other concerns about your child’s health? ____________________________________________________________
____________________________________________________________________________________________________________
Developmental (compared to children this age)
Does your child have any problems with talking or making sounds? Please explain _________________________________________
____________________________________________________________________________________________________________
Does your child have any problems walking, running or moving? Please explain ___________________________________________
____________________________________________________________________________________________________________
Does your child have any problems seeing? Please explain ____________________________________________________________
____________________________________________________________________________________________________________
Does your child have any problems hearing? Please explain ___________________________________________________________
____________________________________________________________________________________________________________
Does your child have any problems using his or her hands (such as puzzles, small building pieces)? Please explain ________________
____________________________________________________________________________________________________________
Stepping Stones PDO * Revive Church * [email protected]
7198 Nolensville Rd. Nolensville, TN 37135 * (615) 776-5057 or (615) 426-1706
Daily Living:
What is your child’s typical eating pattern? _________________________________________________________________________
____________________________________________________________________________________________________________
Is your child on any special diet? Please describe. ____________________________________________________________________
____________________________________________________________________________________________________________
Write N/A (non-applicable) if your child is too young for the following questions to apply.
How well does your child use table utensils (cup, fork, spoon)? _________________________________________________________
____________________________________________________________________________________________________________
How does your child indicate bathroom needs? _____________________________________________________________________
Word(s) for urination? _________________________________________________________________________________________
Word(s) for bowel movement? __________________________________________________________________________________
Special words for body parts? ___________________________________________________________________________________
What are your child’s regular bladder and bowel patterns? Do you want us to follow a particular plan for toileting? ______________
____________________________________________________________________________________________________________
For toddlers, please describe use of diapers or toileting equipment (such as potty, toilet seat adapter) _________________________
____________________________________________________________________________________________________________
What is your child’s regular sleeping patterns? ______________________________________________________________________
Awakes at ______________________ Naps at ______________________________ goes to bed at ___________________________
What help does your child need to get dressed? _____________________________________________________________________
Social Relationships/Play:
What ages are your child’s most frequent playmates? ________________________________________________________________
Is your child friendly? _____________ Aggressive? _________________Shy? _______________ Withdrawn? ___________________
Does your child play well alone? _________________________________________________________________________________
What is your child’s favorite toy? _________________________________________________________________________________
Is your child frightened by (circle all that apply) Animals? Rough Children? Loud Noises? The dark? Storms? Anything else?
____________________________________________________________________________________________________________
Who does most of the disciplining? _______________________________________________________________________________
What is the best way to discipline your child, EXCLUDING physical punishment? ___________________________________________
With which adults does your child have frequent contact? ____________________________________________________________
____________________________________________________________________________________________________________
Does your child use a special comforting item? (such as a blanket, stuffed animal, doll?) ____________________________________
Is there any other information that you wish to share that would assist in meeting your child’s needs? _________________________
____________________________________________________________________________________________________________
Stepping Stones PDO * Revive Church * [email protected]
7198 Nolensville Rd. Nolensville, TN 37135 * (615) 776-5057 or (615) 426-1706
Note: The content of this health history has been taken from “Healthy Young Children: A Manual for
Programs”, a publication of the National Association for the Education of Young Children.
NAEYC, 1509 16th Street, N. W., Washington, DC 20036-1426
Telephone numbers (202) 232-87777 (800) 424-2460 FAX (202) 324-1846
Please initial the following
 I have received a summary of the program requirements. ____________________________________
 I visited the child care facility prior to enrolling my child. _____________________________________
 I understand any changes in the above information must be entered immediately and initialed. ____
The above information is true and accurate to the best of my knowledge.
Parent(s)/Guardian(s) signature _______________________________________________________________
Date child is enrolled __________________________ Date child was withdrawn _______________________
Reason for withdrawal_______________________________________________________________________
Special notes for child care facility or parent/custodian: ___________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Stepping Stones PDO * Revive Church * [email protected]
7198 Nolensville Rd. Nolensville, TN 37135 * (615) 776-5057 or (615) 426-1706