The Nest Academy
Enrollment Application
(PLEASE PRINT)
Today’s Day: ______/______/______
Starting Date:______/______/______
Last Day: ______/______/______
Registration fee received $______Check # ______Date Received ______/______/______
Security Deposit received $______Check # ______Date Received ______/______/______
Security Deposit Refunded $______Check # ______On Date ______/______/______
1. Last Name ______First Name______
Middle Name ______Likes to be called______Sex______
DOB______/______/______Age______S.S.#______-_____-______
2. Registering into (Check one):
· All Day: _____
= Infant Care (new born to 12 mos): ____ M-F (FULL TIME ONLY)
= Toddlers Class (12 mos to 2 yrs): ____ M-F (F/T) ____ M-F (1/2 day) ____ MWF
= Preschool (2 yrs to 3 yrs): ____ M-F (F/T) ____ M-F (1/2 day) ____ MWF
= Preschool (3 yrs to 4 yrs): ____ M-F (F/T) ____ M-F (1/2 day) ____ MWF
= Junior Kindergarten (4’s): ____ M-F (F/T) ____ M-F (1/2 day) ____ MWF
= Kindergarten (5’s): ____ M-F (F/T) ____ M-F (1/2 day) ____ MWF
· Before & After School Programs: ______
Elementary School Attending: ______
School Phone: ( ______) ______-______Grade: ______
3. Previous Child Care Attended ______Phone: ( ______) ______-______
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4. Mother’s Full Name or______Relationship______
Guardian______Relationship______
Address______Apt. # ______
City ______State ______Zip code ______
Home Phone ( ______) ______- ______
Cellular Phone ( ______) ______- ______
Work Phone ( ______) ______- ______Ext. ______
Email address: ______@ ______. ______
S.S. # ______- ______- ______
Employer’s Name ______
Employer’s address ______
City ______State ______Zip code ______
5. Father’s Full Name or______Relationship______
Guardian______Relationship______
Address______Apt. # ______
City ______State ______Zip code ______
Home Phone ( ______) ______- ______
Cellular Phone ( ______) ______- ______
Work Phone ( ______) ______- ______Ext. ______
Email address: ______@ ______. ______
S.S. # ______- ______- ______
Employer’s Name ______
Employer’s address ______
City ______State ______Zip code ______
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6. Persons Authorized to Pick Up:
(a) Name ______
Address______Apt. # ______
City ______State ______Zip code ______
Home Phone ( ______) ______- ______
Cellular Phone ( ______) ______- ______
Email address: ______@ ______. ______
(b) Name ______
Address______Apt. # ______
City ______State ______Zip code ______
Home Phone ( ______) ______- ______
Cellular Phone ( ______) ______- ______
Email address: ______@ ______. ______
(c) Name ______
Address______Apt. # ______
City ______State ______Zip code ______
Home Phone ( ______) ______- ______
Cellular Phone ( ______) ______- ______
Email address: ______@ ______. ______
…………………………………………………………………. ………………/………………../………..………
PARENT’S PRINTED NAME DATE
…………………………………………………………………. ………………/………………../………..………
PARENT’S SIGNATURE DATE
…………………………………………………………………. ………………/………………../………..………
DIRECTOR’S SIGNATURE DATE
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The Nest Academy
STATEMENT OF AGREEMENT
1. Birth Certificate verification must be completed by The Nest Academy Director.
Child’s Full Name______Date of Birth ______/______/______
Child’s Birth Certificate Number______
Place of Birth______Verified on ______/______/______
By ______Title ______
2. I/We understand that my/our child is now formally enrolled at The Nest Academy.
Parent’s Initial______
3. I/We authorize The Nest Academy to care for my/our child (please print your child’s full name)
Child(ren)’s full name……………………………………………………………………………………
Parent’s Initial______
4. I/We understand that if I/We chose to provide food for my/our child, I/we shall be fully responsible
of always making sure that my/our child’s food container shall be clearly labeled with his/her name
and today’s date.
Parent’s Initial______
5. I understand that I am responsible for dropping off my child into the building and coming in for
him/her when he/she leaves each day by signing in and out. If I wish to have someone pick up
my child other than those persons listed on my enrollment application as authorized to do so, I shall
notify in writing The Nest Academy’s director or person in charge beforehand. A picture I.D. will be
required for identification. (The Nest Academy assumes responsibility for your child after he/she is
signed in and delivered to the classroom teacher, when a child is picked up from his/her classroom,
the child then becomes the parent’s responsibility.)
Parent’s Initial______
6. I/We understand and agree that appropriate legal paper work shall be given to The Nest Academy
to be kept on my/our child’s file when the custodial parent requests NOT to release the child to
the other parent.
Parent’s Initial______
7. The custodial parent has the right to visit our Academy as required by @63.2-1813 of the Code of
Virginia.
Parent’s Initial______
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8. I/We agree to abide by the Guidelines of The Nest Academy, as described in their parents’ handbook
I am given and which I should keep with me/us.
Parent’s Initial______
9. Further, I/We agree to pay the fees as required for services rendered. I/We understand that no
reduction will be taken for absences, holidays, vacations of the parents, or illness of the child.
Parent’s Initial______
10. Further, I/We understand that the Fees will be kept at a reasonable rate. However, as economic
conditions change, the fees may be subject to change. I/We understand that I/We will be given
advance notice of fees changes and I/We agree to pay the new fees or give a written two weeks
notice and withdraw my/our child.
Parent’s Initial______
11. Further, in the event of a medical emergency and in the event that I cannot be reached, I/We give
my/our permission to The Nest Academy to contact my/our physician. If they cannot reach the
physician, I/We authorize The Nest Academy to seek immediate emergency care as they may seem
necessary.
Parent’s Initial______
12. Further, I/We understand that The Nest Academy will notify me/us when my/our child becomes ill and that I/We will arrange to have my/our child picked up as soon as possible.
Parent’s Initial______
13. I/We understand and agree NOT to send my/our child to The Nest Academy when he/she is ill or shows signs of illness such as a temperature of 100 degrees and over, intestinal disturbance accompanied by diarrhea or vomiting, any undiagnosed rush, sore or discharging eyes or ears, profuse nasal discharge.
Further, if my/our child contracts any contagious disease such as but not limited to whooping cough, German or regular measles, mumps chicken pox, diphtheria, pinworm, or scarlet fever, I shall keep him/her at home and report his/her condition to The Nest Academy immediately.
Parent’s Initial______
14. Under the new standards for licensed child day centers, the parents will be agreed to inform The Nest Academy within 24 hours or the next business day after his/her child or any member of the immediate household has developed any reportable communicable disease, as defined by the State Board of Health, except for life threatening diseases which much be reported immediately.
Parent’s Initial______
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15. I/We understand that if my child has any allergies, I must notify The Nest Academy with a written statement signed by a Physician.
Further, I/We give permission to The Nest Academy to administer prescription drugs with written instructions from a licensed Physician and written authorization from me/us (parent).
Furthermore, I/We understand that Medicines must be in the original bottle or box with my/our child’s printed full name, current date, dosage amount, Physician’s dosage instructions and number of days to be administered, which shall not exceed 10 days unless re-ordered in writing by the Physician. (Medications will always be stored in a locked container, refrigerated if necessary).
Parent’s Initial______
16. When an authorization for medication expires, we will notify the parent or guardian that the medication needs to be picked up within 14 days or the parent must renew the authorization. We will properly get rid of any Medications that are not picked up by the parent within 14 days.
If sunscreen must be used in our Academy, then parent must write us an authorization noting any known adverse reactions, make sure that the sunscreen is hypo-allergenic and has a minimum SPF of 15, and that it is in the original container labeled with the child’s name.
If diaper ointment or cream must be used in our Academy, then parent must write us in authorization noting any known adverse reactions and make sure that the ointment or cream is in the original container labeled with the child’s name.
* Insect repellent is not allowed to be used in our Academy.
Parent’s Initial______
17. I give my permission for my permission for my child to participate in the neighborhood walks or field trips in an authorized vehicle. I understand that I will be informed of all planned field trips and that I may withdraw my permission for a planned trip if I so desire.
I grant permission for my child to be included in school pictures and give permission for those pictures to be used by the center.
I grant permission for my child to participate in the activities and in the use of the equipment at the Center.
Parent’s Initial______
18. I/We understand that The Nest Academy will report all suspected cases of child abuse as required by the state Licensing Department.
Parent’s Initial______
19. I/We give permission for my child’s pictures to be used in any promotional pieces, such as brochure, web site, newspaper advertisement, for the sole purpose of promoting The Nest Academy.
Parent’s Initial______
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The Nest Academy invites you to visit the facility whenever you like to. Please consult with the Director or Assistant-Director should any problems arise concerning your child whether at home or at school. The Nest Academy seeks your active involvement as parents in the Academy’s program. The Nest Academy strongly encourages you to participate in formal individual parent-teacher conferences scheduled during the year. The Nest Academy also encourages you to take advantage of opportunities for daily contact with our Academy’s Director or Assistant-Director. Your suggestions will enable The Nest Academy to have even higher quality program.
Date / Mother/Guardian’s Name / Mother/Guardian’s Signature
/ / /
Date / Father/Guardian’s Name / Father/Guardian’s Signature
/ / /
Date / Director’s Name / Director’s Signature
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The Nest Academy
EMERGENCY CONTACTS
______/______/______
Child’s Name D.O.B.
______
Home Street Address City State Zip Code
______(______)______-______
Mother’s Name Work Phone Number
_(______)______-______(______)______-______
Home Phone Number Cell Phone Number
______
Employer’s Name
______
Employer’s Street Address City State Zip Code
______(______)______-______
Father’s Name Work Phone Number
_(______)______-______(______)______-______
Home Phone Number Cell Phone Number
______
Employer’s Name
______
Employer’s Street Address City State Zip Code
YOU MUST PROVIDE TWO EMERGENCY CONTACTS – (NOT PARENTS)
********************************************************************
(1)______; ______
Name Relationship
______
Home Street Address City State Zip Code
_(______)______-______(______)______-______
Home Phone umber Work Phone Number
_(______)______-______(______)______-______
Cell Phone umber Alternative Phone Number
______
Employer’s Name and Address City State Zip Code
********************************************************************
(2)______; ______
Name Relationship
______
Home Street Address City State Zip Code
_(______)______-______(______)______-______
Home Phone umber Work Phone Number
_(______)______-______(______)______-______
Cell Phone umber Alternative Phone Number
______
Employer’s Name and Address City State Zip Code
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In the event the above noted persons cannot be located, I hereby give my consent to The Nest Academy to administer first aid or call emergency care for my child under extreme conditions.
I expect that a conscientious effort shall be made to locate me or the designates before any action is taken. If it is not possible to locate me or the designates, any expenses incurred will be accepted by me.
______
Full Name of Parent/Guardian
______
Signature of Parent/Guardian
______/______/______
Today’s Date
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The Nest Academy
EMERGENCY MEDICAL CONSENT
I/We, ………...... , hereby give my/our consent for Emergency Medical Care to be provided for my/our child, ………………………...... While at The Nest Academy.
IN CASE OF EMERGENCY, I/WE CAN BE REACHED AT:
______(______)______-______
Mother/Guardian Work Phone Number
_(______)______-______(______)______-______
Home Phone Number Alternative Home Phone Number
_(______)______-______
Cell Phone Number Email address
______
Employer’s Name
______
Employer’s Street Address City State Zip Code
______
Home Street Address City State Zip Code
********************************************************************
______(______)______-______
Father’s Name Work Phone Number
_(______)______-______(______)______-______
Home Phone Number Alternative Home Phone Number
_(______)______-______
Cell Phone Number Email address
______
Employer’s Name
______
Employer’s Street Address City State Zip Code
______
Home Street Address City State Zip Code
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______(______)______-______
Physician/Clinic Phone Number
______
Hospital preferred
********************************************************************
______
Name Of Insurance / Medicaid
______
Policy Number
______
Other Identification Number
_(______)______-______
Insurance Phone Number
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