LIZ KIDS CHILD CARE: Enrollment Application

$10 Application Fee

Initial:_____

ENROLLMENT APPLICATION

Liz Kids’ Child Care

3301 Patton Drive

Indianapolis, IN 46224

FULL NAME OF CHILD:

NICKNAME:

CHILD’S D.O.B.:

DATE OF ADMISSION:

PARENT/LEGAL GUARDIANS

MOTHER’S NAME:

HOME ADDRESS:

HOME PHONE :( )

CELL PHONE :( )

NAME OF JOB/PLACE OF EMPLOYMENT:

WORK PHONE :( ) _
WORK HOURS:

EMAIL ADDRESS:_________________________________________________

FATHER’S NAME:

HOME ADDRESS:

HOME PHONE :( )
CELL PHONE :( ) ___

NAME OF JOB/PLACE OF EMPLOYMENT:

WORK PHONE :( )
WORK HOURS:

EMAIL ADDRESS:_________________________________________________

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THIS AGREEMENT IS ENTERED INTO BY AND BETWEEN

PARENT’S NAME:

PROVIDER’S NAME:

CHILD’S NAME:

CHILD CARE WILL BEGIN ON / /

CHILDREN OF NEW CLIENTS WILL BE PLACED ON A (2) TWO WEEK TRIAL BASIS. THIS ALLOWS ALL PARTIES TO BECOME ACQUAINTED AND SHOULD DIFFICULTIES ARISE EACH PARTY HAS THE OPPORTUNITY TO TERMINATE CARE IN EARLY STAGES AND SEEK ALTERNATIVE ARRANGEMENTS. A REFUND WILL BE GIVEN BACK.

THE FOLLOWING FORMS MUST BE COMPLETED AND RETURNED BY THE CHILD (REN) FIRST DAY OF CARE. THE LAST FORMS* ARE TO BE FILLED OUT BY A PHYSICIAN AND RETURNED WITHIN 10 DAYS OF START DATE.

REQUIRED FORMS:

EMERGENCY FORM

MEDICAL AUTHORIZATION FORM

SIGNED CONTRACT

SIGNED DISCIPLINE STATEMENT

*PHYSICAL FORM AND IMMUNIZATION RECORD

THE INFORMATION ON THESE FORMS MUST BE ACCURATE AND KEPT CURRENT. IF THERE ARE ANY CHANGES, THE PARENT/GUARDIAN DO HEREBY AGREE THAT THEY SHALL NOTIFY THE PROVIDER IMMEDIATELY.

HOURS OF OPERATION

MONDAY- FRIDAY 6:00A.M. – 6:00P.M.

HOWEVER, NO MORE THAN 10 HOURS PER DAY.

OVERTIME IS OFFERED ONLY ON A PREARRANGED BASIS OR IN THE CASE OF EMERGENCIES. THE FEE IS $10 FOR EVERY ADDITIONAL 10 MINUTE INTERVAL.

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SERVING TIME FOR MEALS

BREAKFAST: 8:30-9:00AM

LUNCH: 12-1PM

PM SNACK 3-3:30PM

LIZ KIDS’ CHILD CARE WILL PROVIDE ALL MEALS FOR YOUR CHILD (REN). WE ASK THAT NO CANDY, SWEETS OR FAST FOOD BE BROUGHT INTO THE DAYCARE. IF YOU WOULD LIKE TO BRING SNACKS FOR SPECIAL OCCASIONS, PRIOR CONTACT IS REQUIRED. ALL INFANT FORMULA AND BABY FOOD IS TO BE SUPPLIED BY THE PARENT.

PAYMENT POLICY

THE CHARGE FOR YOUR CHILD (REN) IS $ PER/WK. IT IS AGREED THAT PAYMENTS SHOULD BE MADE IN FULL ON MONDAY, PRIOR TO CARE WITH NO DEDUCTIONS FOR ABSENCES. PAYMENTS THAT ARE NOT MADE BY THE END OF MONDAY (6:00PM) WILL INCUR A LATE FEE WHICH IS DUE BEFORE CHILD CARE SERVICE CONTINUES. PLEASE NOTE PAYMENTS ARE DUE WEEKLY. THE ACCEPTED FORMS OF PAYMENT ARE: CASH, CASHIER’S CHECK OR MONEY ORDERS. NO PERSONAL CHECKS WILL BE ACCEPTED.

YOU WILL BE NOTIFIED IN ADVANCE OF ANY EXTRA CHARGES TO BE INCURRED FOR FIELD TRIPS OR ADDITIONAL ACTIVITIES. THE PARENTS AGREE TO MAKE PAYMENT FOR THESE ACTIVITIES BY THE DAY OF THE ACTIVITY.

RATE INCREASE WILL BE MADE NOT MORE THAN ONCE PER CALENDAR YEAR. THERE WILL BE AN ANNUAL RATE REVIEW TO ADDRESS COST OF LIVING AND OPERATING COST CHANGES.

DAILY DROP OFF FEE IS $25 PER 10 HOURS, DUE SAME DAY OF SERVICE.

LATE FEE CHARGES:

6:00 – 6:10PM $10
6:11 - 6:20PM $20
6:21 - 6:30PM $30
EACH ADDITIONAL MINUTE IS $5

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PAID HOLIDAY CLOSINGS

LIZ KIDS’ CHILD CARE WILL BE CLOSED:

NEW YEARS EVE, NEW YEARS DAY, CHRISTMAS EVE,CHRISTMAS DAY, MEMORIAL DAY, INDEPENDENCE DAY, LABOR DAY, THANKSGIVING DAY, DAY AFTER THANKSGIVING, MARTIN LUTHER KING JR. BIRTHDAY, AND GOOD FRIDAY CLOSED EARLY (1:00PM).

THE PROVIDER AND STAFF WILL TAKE ONE WEEK (60HRS) PAID VACATION PER YEAR. THE PROVIDER AND STAFF WILL ALSO TAKE ONE WEEK (60HRS) UNPAID VACATION PER YEAR. YOU WILL BE GIVEN A 60 DAY NOTICE PRIOR TO PROVIDERS VACATION. PARENTS ARE RESPONSIBLE FOR ASSURING THEIR OWN ALTERNATIVE CHILD CARE DURING HOLIDAY AND VACATION PERIODS.

YOU (PARENT/GUARDIAN) WILL RECEIVE ONE WEEK (60HRS) OF VACATION TIME WHEN YOUR CHILD CARE FEES ARE WAIVED. A TWO-WEEK NOTICE IS REQUIRED BEFORE VACATION TIME IS TAKEN.

CHILD CARE REQUIREMENTS

DRESS CODE:

PARENT/GUARDIAN ARE ENCOURAGED TO DRESS THEIR CHILDREN IN A MANNER FIT FOR PLAYING, PAINTING, OUT DOORS PLAY, ETC. PLEASE TRY TO REFRAIN FROM SENDING YOUR CHILD WITH EXPENSIVE AND/OR FORMAL CLOTHING AS THE PROVIDER WILL NOT BE RESPONSIBLE FOR ANY ACCIDENTS THAT RESULT FROM NORMAL DAILY ACTIVITIES CONDUCTED.

ILLNESS AND MEDICINES:

THE PROVIDER AND STAFF WILL NO LONGER ADMINISTER ANY FORMS OF MEDICINES TO THE CHILDREN WITHOUT A DOCTOR’S NOTE. IN THE EVENT THAT THE CHILD (REN) IS SICK FOR A PERIOD OF ONE WEEK WILL RESULT IN THE CHILD (REN) BEING OUT OF THE DAYCARE UNTIL THE CHILD IS WELL. THE FEE IS REDUCED TO 50 PERCENT UNTIL THE CHILD IS WELL. THIS IS TO HOLD ENROLLMENT. THE FEE IS DUE ON THE REGULAR BASIS. DOCTORS STATEMENTS MUST BE PROVIDED EXPLAINING THE CHILD'S ILLNESS.

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AT THE PROVIDERS DISCRETION PARENTS OR EMERGENCY CONTACTS WILL BE NOTIFIED IF CHILD (REN) IS BEHAVING IN A “SICKLY” OR “ILL” MANNER, BEGINS TO RUN A FEVER, VOMITS, OR HAS DIARRHEA.YOU WILL BE NOTIFIED AND EXPECTED TO PICK YOUR CHILD UP FROM THE DAYCARE IN A PROMPT MANNER. A SICK CHILD NEEDS THEIR BED.

FOR EVERY TWO DAYS THAT THE PROVIDER IS SICK THE PARENT WILL BE RESPONSIBLE FOR (ONE) OF THOSE DAYS PAY, FOR EVERY FOUR DAYS SICK THE PARENT WILL BE RESPONSIBLE FOR (TWO) OF THOSE DAYS PAY, ETC… THIS ONLY TAKES PLACE IF THE DAYCARE HAS TO CLOSE.

DISCIPLINE:

YOU WILL RECEIVE A TYPED STATEMENT OF OUR DISCIPLINE POLICY WHICH YOU MUST READ, SIGN, AND RETURN PRIOR TO YOUR CHILD (REN)’S FIRST DAY OF CARE.

TERMINATION:

THE PROVIDER RESERVES THE RIGHT TO TERMINATE THIS CONTRACT AT ANY TIME FOR SUFFICIENT REASONS INCLUDING, BUT NOT LIMITED TO: LATE PAYMENT, CONSISTENT MISBEHAVIOR OF CHILD OR UNFORESEEN PROBLEMS WHICH MAY OCCUR WITH THE PARENTS OR THE CHILD.

PARENTS MAY TERMINATE THIS CONTRACT BY PROVIDING A WRITTEN NOTICE TO THE PROVIDER TWO WEEKS PRIOR TO THE EFFECTIVE DATE OF TERMINATION. PARENTS WHO DO NOT PROVIDE THE MINIMUM TWO-WEEK NOTIFICATION SHALL BE RELIABLE FOR TERMINATION CHARGES OF ONE-WEEK CHILDCARE FEES IF SAID NOTICE IS NOT PROVIDED.

PARENT CONFERENCE

PROVIDER WILL HOLD A CONFERENCE WITH THE PARENTS ON AN ANNUAL BASIS ON THE DATE THAT THE CHILD IS ENROLLED TO UPDATE THE PARENT ON THE CHILD’S PROGRESS.

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PROVIDERS RESPONSIBILITIES:

LIZ KIDS’ CHILD CARE WILL PROVIDE A SAFE AND LOVING ENVIRONMENT FOR YOUR CHILD (REN). NUTRITIOUS AND GOOD TASTING MEALS ARE SERVED DAILY. WE WILL HAVE ACTIVITIES THAT SUPPORT THE PHYSICAL AND EMOTIONAL NEEDS OF THE CHILDREN IN OUR CARE. COMPLETELY SUPERVISED INDOOR AND OUTDOOR PLAY IS PROVIDED. TOYS ARE FURNISHED FOR THE CHILDREN. CHILDREN WILL BE GIVEN A DAILY REST PERIOD BETWEEN THE HOURS OF 12-3P.M. IT IS OUR RESPONSIBILITY TO NOTIFY YOU OF ANY CHANGES THAT MAY OCCUR THAT WILL AFFECT THE DAILY ROUTINE OF THE DAYCARE. WE HAVE AN OPEN DOOR POLICY TO ALL PARENTS. WE WILL BE SURE TO KEEP YOU UPDATED WITH ANY CONCERNS OR POSITIVE/NEGATIVE CHANGES IN YOUR CHILD (REN) S BEHAVIOR. IT IS NOT ARE RESPONSIBILITY TO TOILET TRAIN YOUR CHILD, BUT WE WILL ATTEMPT IN ASSISTING YOU.

PARENTS RESPONSIBILITIES:

PARENTS ARE REQUIRED TO KEEP PAYMENTS CURRENT. PARENTS AGREE TO NOTIFY PROVIDER OF ANY CHANGES IN THE CHILD (REN) S ROUTINE. PARENTS WILL SUPPLY DIAPERS (PULL-UPS), WIPES AND LOTION. WHEN THE CHILD IS TOILET TRAINING, PARENTS WILL SUPPLY TRAINING PANTS AND SEVERAL CHANGES OF CLOTHES. REPORT ANY CHANGES IN ADDRESS, PHONES NUMBERS, EMPLOYMENT, WORK HOURS, OR PERSON(S) DESIGNATED TO PICK UP YOUR CHILD, IMMEDIATELY. THIS ENSURES WE HAVE CURRENT CONTACT INFORMATION IN THE EVENT OF AN EMERGENCY.

FIELD TRIPS

CHILD CARE PROVIDER DOES NOT TAKE THE CHILDREN ON ANY FIELD TRIPS.

PARENT COMMENTS:__________________________________________________________________________
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___________________________________________________________________________________
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Initial:______

DISCIPLINE POLICY

1. VERBAL WARNING: ALL CHILDREN ARE ENCOURAGED TO PLAY TOGETHER. HOWEVER, WHEN CHILDREN “ACT OUT” OR MISCHIEVOUS BEHAVIOR OCCURS, THEY WILL RECEIVE A VERBAL WARNING FOR THE FIRST OFFENSE. THE CHILD IS GIVEN AN EXPLANATION AS TO WHY THEIR BEHAVIOR IS NOT APPROPRIATE.

2. SECOND VERBAL WARNING: THIS WARNING IS GIVEN WHEN THE CHILD CONTINUES TO DISPLAY INAPPROPRIATE BEHAVIOR. THE CHILD IS THEN ADVISED OF THE POTENTIAL CONSEQUENCES OF THEIR ACTIONS (EX. “QUIET AREA”).

3. DISCIPLINARY ACTION:

4. CONSULTATION WITH PARENTS: THIS ACTION IS TAKEN WHEN THE CHILD CONTINUES TO BE DISRUPTIVE AND ALL OF THE AFOREMENTIONED METHODS HAVE FAILED (I. E., THE CHILD HAS NOT RESPONDED POSITIVELY TO THE ACTIONS OUTLINED ABOVE).

BY SIGNING BELOW, I ACKNOWLEDGE THAT I HAVE READ THE DISCIPLINARY POLICY OF LIZ KIDS’ CHILD CARE. I HAVE ACKNOWLEDGED THAT I HAVE READ, UNDERSTOOD AND AGREE WITH THE AGREEMENT BETWEEN BOTH PARTIES.

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PARENT SIGNATURE

______________________________________________________________

PARENT SIGNATURE

/ /

DATE

Initial:_____

EMERGENCY PLAN

Please provide at least 3 emergency back-up child care plans in case of child care being closed due to illness, death, vacation, etc..

________________________________________________________________________

Name Number

________________________________________________________________________

Name Number

________________________________________________________________________

Name Number

Ÿ In the case that the provider becomes ill or is contagious to others, the child care will be closed until the provider is no longer contagious. The provider will notify parents by phone call ( 1^st choice) or email at the earliest convenience. (if no emergency provider is available, contact child care answers 317-631-4643)

Ÿ NAME OF PERSON, OTHER THAN PROVIDER, AUTHORIZED TO ACT FOR PARENT IN CASE OF AN EMERGENCY. ___________________ RELATION:__________________

HOME PHONE :( )_______ WORK PHONE :(_____)______________

NAME OF PHYSICIAN:_________ OFFICE PHONE :( )__________

EMERGENCY PHONE :( )

*PLEASE NOTE: IN THE EVENT OF AN EMERGENCY, THIS PERSON WILL BE CONTACTED IF UNABLE TO REACH PARENT(S) OR LEGAL GUARDIANS.

Ÿ TRANSPORTATION PLAN

TO ENSURE THE SAFETY OF YOUR CHILD, PLEASE LIST OTHER ADULTS TO WHOM YOUR CHILD MAY BE RELEASED OR WHO ARE AUTHORIZED TO PROVIDE TRANSPORTATION FOR YOUR CHILD.

NAME NUMBER

Ÿ Providers have emergency evacuation plan (in case of fire or tornado) located by the front entrance of the home.

I UNDERSTAND THAT IN THE EVENT OF A MEDICAL EMERGENCY IF I OR THE EMERGENCY CONTACT CANNOT BE REACHED. MY CHILD CARE PROVIDER WILL SEEK IMMEDIATE HOSPITAL OR CLINIC CARE

PARENT SIGNATURE:____________________________

DATE: / / ______

Liz Kids Child Care Agreement

I, __________________________________________________

(Parent’s Name)

Agree to the following :

_________ Pay fee of _______ per _________ (mo./wk./day/hr.)

_________ Make Child Care payments on _______________ (day of the week)

_________ Late payment fee of _________

_________ Child’s typical arrival time:_________ *(NEEDS TO BE BEFORE 10:00AM UNLESS PRIOR NOTIFIED)

_________ Child’s typical departure time:________

_________ Notify provider when child may have late arrival or will be absent for the day

_________ Follow the Procedures, as outlined in the contract

_________ Supply necessary medical and development information

_________ Notify provider when my child is scheduled for routine visits and obtain a form to complete and return

_________ Complete medication consent form when requesting medication administration

_________Agree to discuss my concerns with the provider

_________Providers are Mandatory Child Reporters

_________ Notify provider in advance if I plan a birthday celebration for my child, or intend to bring in special treats to be served to all children

_________ I have read and understand the provider’s philosophy on discipline

_________ Provide the provider with the following items that are necessary for child’s care

_________Wet Wipes

_________ Diapers

_________ Blanket

_________ Formula (infants only)

_________ Change of clothes

__________Provide information on how to contact me in an emergency situation, which I will update when changes occur and every 6 months

__________Notify provider when my child is ill or any family member has a contagious disease

__________ Designated persons to whom the child may be released are:

1.______________________________________
2.______________________________________

3.______________________________________

LIZ KIDS

ALL ABOUT ME

Help us get to know your child a little better by answering a couple question about your child.

*What words best describe your child? ________________________________________________________________________________________________________________________________________________

*How well does your child get along with other children?

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*What is your child’s favorite games/activities?

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*What makes your child mad or upset?

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*What do you find to be the best way of handling your child? (discipline issues)

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Any comments: ____________________________________________________________________________________________________________________________________________________________________________________________________________________

LIZ KIDS CHILD CARE

Enrollment Application

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