Little MavericksLearning Center C h ild In fo rm a tio n a n d Med ic
Transcription
Little MavericksLearning Center C h ild In fo rm a tio n a n d Med ic
Little Mavericks Learning Center Summer Program Program Information Little Mavericks’ Summer Program is open to all children ages 1-12 Especially for Lil Mavericks Children: Lil Mavericks: 1-3 (not potty trained) Mavericks 3 -5 Big Mavericks elementary school aged Dates: Parachute Fun Teddy Bear Picnics Tea Parties Lemonade Parties Sensory Exploration Water Play Movement and Dance Animal Parades Toddler Olympics Wagon Rides Nature Walks Especially for Mavericks May 15-Aug 11 closed July 4th Campus Field Trips: CMU Bio Building~ Green House CMU Library Children’s Center CMU Recreation Center Weekly: Picnics Trips to the beach Fun Food Friday Water Day Movie Day Daily Rates: Lil Mavericks: …..… $30.00 Mavericks: ……..….. $25.00 Big Mavericks: ……. $20.00 daily …………….……….. $25.00 special activity days (See registration calendar for details) Registration Fee: $25.00 per child Hours: Monday-Friday………..6:45 am-5:30 pm Food: Lil Mavericks & Mavericks: Morning and afternoon snack provided by LMLC Sack Lunch provided by the parent Big Mavericks (school aged) Parents provide all snacks and lunch for their child Especially for Big Mavericks Weekly: Movie Day Swimming Hiking Fishing Sports Day Arts and Crafts Museums Nature Center Math and Science Center MC Public Library Police and Fire Stations Bike Trips Bike Rodeos Playing at the Park Banana Fun Park (End of Summer) Little Mavericks Learning Center Summer Enrollment Packet (1 year – 5 years) Child Information and Medical Information Child’s Name_____________________________________ Birth Date_____________________ Gender_____________ Address_______________________________________ City________________________________ Zip_____________ Name(s) and age(s) of siblings _________________________________________________________________________ Mother’s Name________________________________ Father’s Name_____________________________________ Birth Date____________________________________ Birth Date________________________________________ Social Sec #_________________________________ Social Sec #______________________________________ Address______________________________________ Address__________________________________________ Phone #______________________________________ Phone #__________________________________________ Employer_____________________________________ Employer________________________________________ Address______________________________________ Address_________________________________________ Phone #______________________________________ Phone #_________________________________________ CMU 700#____________________________________ CMU 700 #______________________________________ Custody issues or concerns If there are custody issues involving your child, Little Mavericks must have copies of court papers. Health History Describe any surgeries, accidents, chronic illnesses or handicapping conditions. Allergies: _____________________________________________________________________________________ Food Restrictions_______________________________________________________________________________ Physician’s Statement (Statement of health Signed by Physician) I find _______________________________to be in good health and able to attend Little Mavericks Learning Center . Are there restrictions to the child participating in any activities? If yes, please describe. _____________________________________________ Physician’s Signature _______________________________ Date Please attach a copy of your child’s immunization records Non Parent Emergency Contacts Please list the persons you would like contacted (in order of priority) if you cannot be reached in case of emergency. For the safety of your child, we will request all authorized release persons with whom staff are not familiar to provide Government-issued photo identification at the time of pick-up. Persons listed below are authorized to pick up the child in case of a campus wide or building evacuation. These persons will also be called in if the parent cannot be reached during the school day if the child needs picked up for any reason. Contacts must live locally Emergency Contact Information Name__________________________________ Phone #___________________Relationship______________________ Name__________________________________ Phone #___________________Relationship______________________ Name__________________________________ Phone #___________________Relationship______________________ Name__________________________________ Phone #___________________Relationship______________________ Name__________________________________ Phone #___________________Relationship______________________ Your child will not be released without prior written authorization to anyone not listed above. In the event you call a pickup authorization into the school because you are unable to submit your authorization in writing, we will use your personal information from this packet to verify your identity. _______________________________________________ ______________________________ Parent’s Signature Date Authorization to Treat a Minor This consent shall remain effective until ________________, of the year __________. Medical Authorization I (we) the undersigned parent, parents or legal guardian of __________________________________, a minor, do hereby authorize and consent to any x-ray examination, anesthetic, medical or surgical diagnosis rendered under the general or special supervision of any member of the medical staff and emergency room staff licensed under the provision of the Medicine Practice Act, of a Dentist licensed under the provisions of the Dental Practice Act, and on the staff of any acute general hospital holding a current license to operate a hospital from the State of Colorado Department of Public Health. It is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care being required but is given to provide authority and power to render care, which the aforementioned physician in the exercise of his best judgment may deem advisable. It is understood that effort shall be made to contact the undersigned prior to rendering treatment to the patient, but that any of the above treatment will not be withheld if the undersigned cannot be reached. List any restrictions: Signature of Father, Mother, or Legal Guardian: _______________________________________________________Date: _____________________ _______________________________________________________Date: _____________________ Child’s Birth Date: _________________________________ Last Tetanus Booster: ____________________ Allergies to Drugs or Food: _________________________________________________________________________________ Any Special Medications or Pertinent Information: _________________________________________________________________________________ _____________________________________________________ Preferred Hospital: _____________________________________Phone:_______________________ Child’s Physician: ______________________________________Phone:_______________________ Insurance Company: _________________________________________________________________ Policy Number: _______________________________________ Please read and initial each item in the box, then sign at the bottom. Video Release I understand the use of video is limited to those of educational quality and those that are age appropriate. Videos are used for teaching purposes, special occasions and during bad weather. On occasion full length children’s movies are viewed. Nap Cot Authorization I have discussed the nap routine with the staff and I have seen the cot/mat my child will sleep on. I hereby give permission for my child to use the cots during nap time. Field Trip I understand that the children take walking field trips around campus. If field trips take children away from campus, I will be notified and a special permission slip will be provided. Authorizations Sun Screen I understand that sunscreen will be applied only with written authorization and instructions for application. I will provide LMLC with sunscreen that is labeled with my child’s first and last name along with Instructions for application. Permission Releases I hereby grant permission for my child_____________________________ to participate in all activities at Little Mavericks Learning Center. These will include, but not be limited to, field trips and walks, cooking experiences, evaluations, videotaping of classrooms, publicity photos connected with the program, and use of all play equipment in the building. I also understand the school will not be responsible for anything that happens as a result of false information given at the time of enrollment. I understand the school will not be held responsible for a child who has not been signed in when he/she arrives for the day. In consideration of Little Mavericks Learning Center admitting my child into its program, I hereby for myself, my heirs, administrator and assign, waive and release any and all rights to and claim of any nature against LMLC and their organization, representatives, successors and assign for any and all injuries or damages of any nature which my child may suffer in the program. I also acknowledge that I have read and agree to the policies set forth in the Parent Handbook. ______________________________________ Parent signature ______________________________ Date Tuition Tuition is due at the time the monthly summer calendar is turned in. Delinquent accounts are daycare accounts that have a balance remaining after day care tuition is due. If a balance remains after the 15th of the month tuition is due, a child will no longer be able to attend Little Mavericks until the balance is paid off. Tuition Agreement Any account that goes without a payment for 90 days will be sent to collections. Late fee: Late payment will result in a fee of $5.00 per day for each day after due date. Return checks: A $22.00 charge added to your account. Late pick up: All children must be picked up by 5:30pm. Little Mavericks charges a late fee of $5.00 for every fifteen minutes a child remains at the center past the deadline The fee will be added to their next tuition bill. By signing this agreement, I am stating that I have read and agree to all tuition policies and procedures of Little Mavericks LEARNING CENTER. ______________________________________________ Parent’s signature __________________ Date Child’s Name_____________________________________________________ Indicate the time you would like your child at LMLC (example 8:00am-5:00 pm) Sunday Monday Tuesday Wednesday Thursday Friday Saturday May 15 18 19 20 21 22 25 26 27 28 29 Tuition is per day Toddlers $30.00 Total number of days (X) $30.00=__________ Preschool $25.00 Total number of days (X) $25.00=__________ Total Tuition: $______________ May’s calendar and payment is due by May 1, 2015 Child’s Name_____________________________________________________ Indicate the time you would like your child at LMLC (example 8:00am-5:00 pm) June Sunday Monday Tuesday Wednesday Thursday Friday 1 2 3 4 5 8 9 10 11 12 15 16 17 18 19 22 23 24 25 26 29 30 Saturday Tuition is per day Toddlers $30.00 Total number of days (X) $30.00=__________ Preschool $25.00 Total number of days (X) $25.00=__________ Total Tuition: $______________ June’s calendar and payment is due by May 18, 2015 Child’s Name_____________________________________________________ Indicate the time you would like your child at LMLC (example 8:00am-5:00 pm) Sunday Monday Tuesday Wednesday Thursday Friday 1 2 3 7 8 9 10 13 14 15 16 17 20 21 22 23 24 27 28 29 30 31 Saturday July CLOSED Tuition is per day Toddlers $30.00 Total number of days (X) $30.00=__________ Preschool $25.00 Total number of days (X) $25.00=__________ Total Tuition: $______________ July’s calendar and payment is due by June17, 2015 Child’s Name_____________________________________________________ Indicate the time you would like your child at LMLC (example 8:00am-5:00 pm) Sunday Monday Tuesday 3 4 10 11 Wednesday 5 Thursday 6 Friday Saturday 7 August CLOSED Teacher Work Days Tuition is per day Toddlers $30.00 Total number of days (X) $30.00=__________ Preschool $25.00 Total number of days (X) $25.00=__________ Total Tuition: $______________ August Calendar and payment is due by July 18, 2015