ENROLLMENT APPLICATION Lifeline Child Care Center
This application should be completed by all parents/guardians who seek admission for their children to our day care program. Parent/Guardians' Name:___________________________________________
Last First Middle
Spouses' Name:____________________________________________________
Last First Middle
Physical Address:__________________________________________________________
Mailing Address:___________________________________________________________
City:_________________ State:___________ Zip Code:__________________ Business Address:_________________________________________________ City:_______________ State:_____________ Zip Code:____________ Home Phone: (____)____________ Business Phone:(____)____________ Number of children you wish to enroll in the program:_________ Child's Physical Address:___________________________________________ Child's Mailing Address:____________________________________________ City:______________ State:______________ Zip Code:________________ List the following information about each child: Name: Age: Birth Date: Allergies: Please attach the following pieces of information to this application:
1. Any Health and Development information concerning the child.
2.Copies of current reports of physical examinations, immunizations, and a list of ALL allergies.
3. List the name, address, and telephone number of the doctor who should be contacted in case of a medical
emergency. Volunteer Experience: Are you willing to volunteer your time in order to make your child's experience and education more efficient? (yes, no) If yes, please list the areas in which you feel comfortable volunteering
(Read Aloud, After School Tutoring, Arts and Crafts, etc.)
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________ Authorized Adults: Please list three individuals who are authorized to take your child/children from the facility. Feel free to attach another sheet of paper listing any other adults, and he information below, who have your authorization to take your child/children from the facility. Without this information the application process will be delayed. Name:____________________________
Address:__________________________
__________________________
__________________________
Daytime Phone:_____________________
Evening Phone:_____________________
Relationship to reference:______________
**Can this person assume responsibility for
your child if you cannot be reached in case of emergency? (yes, no) Name:____________________________
Address:__________________________
__________________________
__________________________
Daytime Phone:_____________________
Evening Phone:_____________________
Relationship to reference:______________
**Can this person assume responsibility for
your child if you cannot be reached in case of emergency? (yes, no) Name:____________________________
Address:__________________________
__________________________
__________________________
Daytime Phone:_____________________
Evening Phone:_____________________
Relationship to reference:______________
**Can this person assume responsibility for
your child if you cannot be reached in case of emergency? (yes, no) Fees, Payment Plans, and Fee Schedule:
* A deposit fee must be given before admission and enrollment will be approved. *The following costs are daily fees which must be paid on the first day of the week (Monday). Ages: Non-Church Members' Fees: Supporting Church Members' Fees: | | | 2 year-3 year old | $19.50 | 10% discount on total fee | 4 year - 5 yr old | $18.50 | 10% discount on total fee | After School program | $12.00 | 10% discount on total fee | | | | *Prices subject to change | | |
Waiver and Consent:
I,__________________________, hereby certify that the information I have provided on this application for enrollment is true and correct.
In the event that my application is accepted and my child/children are enrolled by Lifeline Child Care Center, I agree to abide by and be bound by the policies of both Lifeline Child Care Center and Princeton Church of God.
In the event of a medical emergency, Lifeline Child Care Center employees have my permission to use emergency medical services when necessary.
I understand that my child/children cannot be enrolled in this or any child care program without an entrance interview and subsequent approval.
I understand that admission and enrollment to the Lifeline Child Care Center is based on the date of the completed application, the entrance interview, and payment of a down payment.
I have read this waiver and the entire application, and am fully aware of its contents. I sign this consent freely and under no duress or coercion.
________________________________________________________
Signature of Applicant Date
________________________________________________________
Witness Date Give this application to the Care Center Secretary. |
