Parent/Guardian Information Registration Date: /

Registration Form

Parent/Guardian Information Registration Date: / /

Mother/Guardian First Name:______M.I.______Last Name:______

Address______

Occupation:______Home Phone:______

Employed By:______Work Phone:______

Work Address:______Work Hours:______

Cell Phone:______Email______

Last 4 digits of social security #: ______Date of birth: ______

[ ] Custodial Parent (If married, mark both parents)

Marital Status: [ ] Married [ ] Single [ ] Divorced [ ] Separated [ ] Widowed [ ] Other______

Father/Guardian First Name:______M.I.______Last Name:______

Address______

Occupation:______Home Phone:______

Employed By:______Work Phone:______

Work Address:______Work Hours:______

Cell Phone:______Email______

Last 4 digits of social security #: ______Date of birth: ______

[ ] Custodial Parent (If married, mark both parents)

Marital Status: [ ] Married [ ] Single [ ] Divorced [ ] Separated [ ] Widowed [ ] Other______

Child Information

1st Child First Name:______M.I._____Last Name:______

Name child prefers to be called:______Grade/Class______

Child’s Address______Gender: [ ] Male [ ] Female

Date Of Birth:______Photographs: May we take and maintain a photo of your child for advertising, on our website and in our center? [ ] YES [ ] NO Preschool [ ] YES [ ] NO 2nd Child First Name:______M.I._____Last Name:______

Date Of Birth:______Photographs: May we take and maintain a photo of your child for advertising, on our website and in our center? [ ] YES [ ] NO Preschool [ ] YES [ ] NO

3rd Child First Name:______M.I._____Last Name:______

4th Child First Name:______M.I._____Last Name:______

Emergency Contacts & Authorized Pickup Persons:

Emergency Contact/Pickup Name:______Phone______

Relationship to Child______

[ ] Able to pick up all children in family

[ ] Not Able to pick up the following children:______

2nd Contact/Pickup Name:______Phone______

[ ] Not Able to pick up the following children:______Registration Form

3rd Contact/Pickup Name:______Phone______

4th Contact/Pickup Name:______Phone______

Relationship to Child______[ ] Able to pick up all children in family

Immunizations

[ ] I have provided copies of my child’s immunization form to Kangaroo Clubhouse.

[ ] I hereby request exemption of the child, named on the front, from the immunization requirements for preschool entry because all or some immunizations are contrary to my beliefs. I understand that in case of an outbreak of any one of these diseases, my child may be temporarily excluded from attending for his/her protection.

SUNSCREEN PERMISSION

I give permission for Kangaroo Clubhouse to apply sunscreen to______(child’s name) as needed. I understand that I may be asked to supply PABA-Free sunscreen for my child.

TYLENOL PERMISSION

I give permission to Kangaroo Clubhouse to administer Tylenol to ______(child’s name) as needed per directions for fever to try to reduce fever before I am called to pick up my sick child

Parent/Guardian Signature______Date______

FIRST AID AND EMERGENCY MEDICAL CARE CONSENT

I authorize staffs at the Kangaroo Clubhouse that are trained in the basics of first aid/CPR to give my child first aid/CPR when appropriate. I understand that every effort will be made to contact me in the event of an emergency requiring medical attention for my child. However, if I cannot be reached, I hereby authorize the program to transport my child to the nearest medical care facility and/or to ______, and to secure necessary medical treatment for my child. Is your child currently taking any medications? If yes, what kind? ______

2nd Child: ______3rd Child: ______4th Child: ______

Does your child have any allergies (food or environmental)? ______

Any important health concerns we should be aware of? ______

Does your child have any special interests that may help us find activities that they enjoy? ______

______

How do you comfort your child? ______

Does your child nap? ______

What should we know as teachers about your child(ren) to work with them more effectively? ______

______

Has your child(ren) had previous child care experience? If yes what was it like? ______

______

Any special family circumstances we should be aware of? ______

______

Is there any other information that would be helpful to our management & teaching staff?

______

Signature

Parents Signature: ______Date______Registration Form

Upon enrollment you will need the following forms filled out and in our possession before we can assume the responsibility of caring for your child. NO EXECPTIONS! This is to ensure that your child will get the very best possible care from us!

 Registration Packet (7 pages)

 Immunization Records

 Infant Feeding Instruction Form (if necessary)

 Consent to Administer Medication (if necessary)

SIGNATURES

There will be a yearly revision to this handbook and the accompanying contract. All families will be responsible for reviewing the updated copy online. We reserve the right to make changes in rates and policies as we deem necessary. We will provide you with a written two week notice (via newsletter, email, or letter sent home with your child) of any increase in fees or significant changes to this agreement.

By signing this contract, parent/guardian agrees to abide by the written policies in the handbook provided by Kangaroo Clubhouse, and that you have accessed our Parent Handbook on the website (Kangarooclubhouse.com).

If you are unable to access our website or would like a paper copy of the handbook please initial here and one will be provided to you. ______

Providers Signature: ______Date: ______

Mother/Legal Guardians Signature: ______Date: ______

Father/Legal Guardians Signature: ______Date: ______Child Care Pricing 2016

0-2 years 3-4 years 5 & up

5 days $560/month $524/month $496/month $376/month

1 day $152/month $148/month $144/month $136/month

Drop In- Full day $40 (first child) $25 (siblings)

Drop In- 5 hours or less $25 (first child) $15 (siblings) Registration Form

Rate Agreement

I understand that my tuition rates are as follows: $______/month and payments are due in full on the 1st of each month or half tuition on the 1st and half tuition on the 15th. If tuition is not paid on designated due dates late payment fees will be applied to my account. NOTE: ______Late Payment Fee: $10.00/day Registration Fee: $50.00/child (nonrefundable)

Late Pick Up Fee: $5.00/1st 5 min. then $1.00/min (due the next day)

Returned Checks: $25.00

Sign In/Out Fee: $5.00/every time staff have to do it for you

School Age Kids: $10.00 (daily amount to be charged when school is out and child is attending daycare during breaks)

Field Trips: Field trips will vary in cost, and is due before the field trip leaves. You will be notified ahead of time.

Diaper Fee: You will be charged .50 cents per diaper borrowed from the center if you do not bring diapers for your child after staff has given proper notice of low stock.

Clothing Fee: You will be charged $2.00 per item borrowed from the center and not returned after your child has had an accident. These clothes are donated to us for temporary use for children in our care that have accidents we need them to be returned so that we can keep our kids clothed.

Schedule: Please fill in your child’s weekly schedule. These will be your set days each week. Days may not be traded, switched or credited to another week.

Monday: ______Tuesday: ______Wednesday: ______

Thursday: ______Friday: ______Flex Plan: ______

Director’s Signature: ______Date: ______Mother/Legal Guardian Signature: ______Date: ______

Father/Legal Guardian Signature: ______Date: ______