Mount Hope Academy
6823 Harrison Road
Fredericksburg, VA 22407
Phone (540) 785-4631 Fax (540) 548-2540
Registration Package
“COME LEARN WITH US”
ABEKA CURRICULUM
SOL PREP AND PALS Assessment
Hours of Operation: 5:30AM – 6:30PM
Breakfast, Lunch & Afternoon Snack Served
Please Provide a Morning Snack
Revised: August2013
Mount Hope Academy Admission Form
Date: ______
Name of Child ______Date of Birth ______Age______
Place of Birth: ______Sex of Child ______
Address ______
Home Telephone No. ______Number of other siblings & ages ______
Who will pick up child? 1) ______2) ______
Approximate time of arrival? ______Time of Departure? ______
PERSONAL DATA
Name of Mother: ______
Address ______
Home Telephone No. ______Work Phone No. ______
Cell Phone No. ______
Business Address ______
Email Address ______
Name of Father ______
Address ______
Home Telephone No. ______Work Phone No. ______
Cell Phone No.______
Business Address ______
Email Address ______
Marital Status of Parents: Married____ Divorced____ Separated____ Single____Widowed____
IN CASE OF EMERGENCY
1. Name ______Address ______Tel.No.______
2. Name ______Address ______Tel.No.______
3. Name ______Address ______Tel. No.______
1. Pediatrician ______Address ______Tel. No.______
2. Pediatrician ______Address ______Tel. No.______
Date child will enter program: ______
Name of siblings currently enrolled in program: ______
I ______am the ______parent ______legal guardian ______other (please specify) of this child.
ABOUT YOUR CHILD
Is this your child’s first child care/preschool experience? YesNo
Name of all other child care programs/schools child has been enrolled in:
Name______location (city and state)______
Name______location (city and state)______
Does the child have any fears, illnesses, or allergic conditions we should be aware of? Yes No
If so, what are they so that we may address them properly?
______
Describe your child’s personality: ______
______
Person(s) Authorized to Pick Up Child
Person(s) Not Authorized to Pick Up Child
ALLERGY RELEASE FORM
I HEREBY NOTIFY THE STAFF OF Mount Hope Academy that my child ______
is allergic to the following substances, and could suffer a negative reaction if exposed to these substances. Attached is a Physician’s Verification of this allergy.
______
______
______
I understand that the staff will to the best of their ability monitor any food my child eats or is exposed to, and I hereby release Mount Hope Academy and its staff from any liability which may result from my child’s accidental exposure to such foods.
I authorize Mount Hope Academy’s MAT certified staff members to administer the following medications to my child on an emergency basis to alleviate reactions to the above foods:
______
______
______
______
I understand that it is my responsibility to assist in the training of emergency care required by my child and that the staff will to the best of their ability follow the procedures. I release Mount Hope Academy and its staff from any liability, which may result from the administration of the above medication.
Signature: ______
Date: ______
Notarized seal: ______
CONSENT FOR EMERGENCY TREATMENT
I give my consent to the personnel of Mount Hope Academy to give emergency treatment to my child in the event of illness or injury, while he/she is at Mount Hope Academy.
I understand that only emergency treatment will be given and that I am responsible for follow-up treatment if needed.
Child’s Name: ______Age: ______
SIGNIFICANT MEDICAL HISTORY:
Allergies: ______
Unusual Drug Response: ______
Medication: ______
Epilepsy: ______
Rheumatic Fever: ______
Heart Disease: ______
Other (Asthma or other medical conditions): ______
______
Parent or Guardian Signature Date
______
Work Phone Number
______
Home Phone Number
NOTARIZED: ______
MEDICAL CONSENT FORM
Completion of this form is voluntary however; the penalty for not completing it may be a delay of processing or denial of admission. This information is gathered to promote the health and safety of all children enrolled.
Child’s Name: ______DOB: ______
Address: ______
______
Parent’s Name: ______
Day Telephone Number: (Mother) ______(Father) ______
Emergency Contact: ______Tel No.: ______
Physician or Clinic: ______
(Name)(Address)
1. I hereby give consent for Mount Hope Academy:
a. To obtain necessary medical information
b. To provide emergency medical care in the event that neither parent nor guardian can be reached.
2. I also acknowledge as my responsibility and consent to make available to my child when and if necessary, later:
a. A complete physical examination, including urinalysis, hematocrit, and follow-up care.
b. A TB skin test
c. Childhood shots, pertussis, tetanus (DPT), smallpox, polio vaccine, and measles vaccine.
d. Psychological evaluation and treatment.
e. Vision, hearing and dental services
Signature: ______Date: ______
Notarized: ______
Mount Hope Academy’s Decision to Administer Medications Plan
Mount Hope Academy has made the following decision regarding the administration of medications to a child in our program:
We WILL administer prescription and non-prescription medications. Medications will be administered by a staff member who has taken MAT (Medication Administration Training) at10:00 a.m. and 3:00 p.m.Please adjust your child’s medication schedule accordingly. We will not be able to administer medication at any other time. A parent/guardian/custodian may come to the Academy at any time to administer his/her child’s medications.
If your child is on any medication, which needs to be administered while he/she is at school, he/she must have on file in the office the authorization for administration form. This form must be updated every six months for long-term medication and every ten days for short-term medication. This form is available in the Academy office and online at It must have the physician’s signature (if administered more than 10 days). The medication to be administered will be kept in a locked cabinet in the Academy office. The medicine must be in the original container. Over-the-Counter medication should be labeled with the child’s first and last names. Prescription Medication should be in a child resistant container. It must have the original pharmacy label that includes the following items: (1) Child’s first and last name, (2) Doctor’s Name, (3) Pharmacy name and telephone number, (4) Date Prescription was filled, (5) Name of Medication, (6) Dosage of the medication, (7) Route of administration, (8) How often to give the medication, (9) Date the medication is to be discontinued or length of time, in days, the medication is to be given. Parents must provide administration tools, such as dosing spoons, oral medication syringes, pill crushers, etc. STUDENTS MAY NOT TRANSPORT MEDICATION TO AND FROM SCHOOL.
Authorized Staff to Administer Prescription Medications
MHA will administer prescription medication in accordance with the physician’s or other prescriber’s instructions and in accordance with the MAT standards of practice. Only a provider who has successfully completed MAT or has appropriate licensure to administer prescription medications and is listed as a medication administrator in this plan will be permitted to administer prescription medications at MHA.
We understand that any individual listed in this section as a medication administrator is approved to administer prescription medications using the following routes: topical, oral, inhaled, eye, and ear, medication patches and epinephrine using an auto-injector device.
We understand that if a child enrolled in MHA requires prescription medication to be administered rectally, vaginally, by injection or by another route not listed above, I will follow the procedures outlined in MAT for children with special health care needs.
We understand that to be approved to administer prescription medication, all individuals listed in this plan (unless the individual is licensed to administer prescription medications) must have a valid:
- Medication Administration Training (MAT) certificate;
- CPR certificate which covers all ages of the children MHA is approved to care for as listed on our registration; and
- First aid certificate which covers all ages of the children MHA is approved to care for as listed on our registration.
Medication Administrators
MAT certificates (or documentation of licensure to administer prescription medication), age-appropriate first aid certificates, and CPR certificates for the staff listed below will be kept on site and be available upon request.
Corliss Shepherd Ruby Houston
Sharita Minor Juanita Montgomery
Sophia Byrd Emyli Shepherd
Tisha Thrash
Confidentiality Statement
Information about any child at MHA is confidential and will not be given to anyone except VDSS’ designees or other persons authorized by law unless the child’s parent or guardian gives written permission. Information about a child enrolled in MHA will be given to the local department of social services if the child receives a day care subsidy or if the child has been named in a report of suspected child abuse or maltreatment or as otherwise allowed by law.
Rehabilitation Act of 1973
We understand that if MHA receives any federal funding (such as child care subsidy from a local department of social services), We are subject to Section 504 of the Rehabilitation Act of 1973 which is similar to the provisions of the Americans with Disabilities Act. If a child enrolled in MHA now or in the future is identified as having a disability covered under the Rehabilitation Act, We will assess the ability of MHA to meet the needs of the child (for further information on the Rehabilitation Act seek legal counsel and/or go the following website:
Provider Statement
We understand that it is our responsibility to follow MHA’s Decision to Administer Medication Plan and all health and infection control regulations applicable to our program.
We will verify and document the credentials for all new staff certified to administerprescription medications before the staff is allowed to administer prescription medications to any child at MHA. MHA’s Decision to Administer Medication plan will be made available to parents at enrollment, whenever changes are made and upon request.
Facility Name: Mount Hope Academy / Date: February27, 2013Parent’s Signature: / Date:
Permission to Apply Topical Medication
Mount Hope Academy’s staff has permission to apply First Aid Antibiotic/Pain Relieving Ointment (Neosporin or Generic Brand) to ______. I
Child’s Name (print)
understand that this medication will help prevent infection and provide temporary relief of pain or discomfort in minor cuts and scrapes.
______
Parent’s Name (print)
______
Parent’s Signature Date
EMERGENCY EVACUATION PERMISSION SLIP
In the event of an emergency evacuation, Mount Hope Academy has my permission to
transport my child/ren ______using the Academy
(Child’s Name)
vans, staff vehicles, and/or parent vehicles to the following facilities:
Creative Childcare Academy 7001 Harrison Road Fredericksburg, VA 22407 (540) 548-8003
Salem Fields Early Learning Center 11120 Gordon Road Fredericksburg, VA 22407 (540) 786-6292
Minnieland at the Castle
6306 Old Plank Road, Fredericksburg, VA 22407
(540) 786-2434
______You have my permission to transport my child.
______You do not have my permission to transport my child.
______
Please Print Signature Date
Agreements:
The Academy agrees to notify the parent/guardian/custodian whenever the child becomes ill and the parent agrees to pick the child up no later than one hour after notification.
The parent/guardian/custodian agrees to abide by all Academy policies as outlined in the parent handbook.
The parent/guardian/custodian authorizes the Academy to obtain immediate care if any emergency occurs when he/she cannot be located.
Weekly tuition payments are due in advance by closing on Fridays. Payments received after this time will be assessed a $30 late fee. Delinquent accounts must be paid-in-full by close of business the following day. Your child/children will not be permitted to attend the Academy until payments are made in full.
I have read and understand the policies above and would like to register my child for enrollment in the program. I have attached the non-refundable registration fee.
SIGNATURES:
Date: ______
Parent/Guardian/Custodian: ______
Administrator: ______
CONTRACT OF ADMISSION BETWEEN MOUNT HOPE ACADEMY AND PARENTS OF ENROLLING CHILD FOR CHILD CARE SERVICES
This contract is made ______day of ______, 20__, by and between Mount Hope Academy, Fredericksburg, Virginia, hereby known as MHA and ______
______, hereinafter know as the Parent(s).
Now, therefore, in consideration of the agreement set forth herein, MHA and the Parent(s) hereby agree that Mount Hope Academy will enroll the Parent(s) child upon the following terms and conditions:
FOR THE REGISTRATION of (the child) ______to be enrolled in the following program: Full time
______I am enrolling my child in K3 or K4. I understand that my weekly tuition fee will be $140.00.
______I am enrolling my child into the half day pre-school program (8:00 a.m. – 12:00 noon). I understand that my weekly tuition will be $90.00.
______I am enrolling my child in K5, First grade, or Second grade. I will not utilize the aftercare program. I understand that my weekly tuition fee will be $100.00.
______I am enrolling my child in K5, First grade, or Second grade as well as the aftercare (3:30-6:30 p.m.) program. I understand that my weekly fee will be $120.00 ($100.00 plus $20.00 aftercare fee).
I (we) agree to pay a non-refundable registration fee. I (we) also agree to pay tuition on a weekly basis. I (we) understand that if I (we) do not pay tuition by the close of business on Friday of the preceding week tuition is due, I (we) will incur a $ 30 late charge. Delinquent accounts must be paid-in-full by close of business the following day. Your child/children will not be permitted to attend the Academy until payments are made in full. Fees unpaid seven (7) working days after the due date will serve as a notice of intent to remove the child from MHA and will constitute forfeiture of any monies due.
I (we) understand that a fee of $2.00 per minute, per child will be charged if I (we) pick up my (our) child after the scheduled closing time of 6:30 P.M. I understand that in order to avoid this fee, I should contact someone on my emergency list to pick up my child/children
(NOTE: Late pick-up fees are due at time of pick-up.)
AS A CONDITION OF ENROLLMENT, I (we) understand that my (our) child is accepted on a trial basis initially and observation pertaining to the child’s ability to adjust to the day care setting will be made during this period (2 to 4 weeks).
WITH RESPECT TO ABSENCES, I (we) understand that weekly tuition payments will not be prorated or lifted should my (our) child leave for a vacation. I (we) understand that tuition is paid on the regular schedule unless other arrangements are made with the Director.
If my (our) child is absent due to an extended illness tuition will not be lifted according to the Tuition Policy in the Parent(s)Handbook. The tuition rate will be 50% of the normal weekly tuition rate beginning the second week of the illness.
IN CONSIDERATION OF THE WITHDRAWAL OF THE CHILD FROM ENROLLMENT, I (we) understand that I (we) must give two (2) weeks advanced notice in writing should I (we) elect to withdraw my (our) child from MHA for any reason. If I (we) do not give two (2) weeks written notice, then I (we) may forfeit any monies due.
If I (we) wish to re-enroll my (our) child at a later time, I (we) may leave my (our) advanced deposit with MHA. I (we) understand that my (our) name will be placed at the top of the waiting list for re-admittance, but that a slot cannot be guaranteed.
MHA reserves the right to terminate the enrollment of any child for reasons of non-cooperation, delinquency in payment of fees, or inability of child or parent to adjust to the MHA program guidelines, as determined by the Board.
REGARDING PARENT INVOLVEMENT, I (we) understand that parent participation in activities associated with MHA, by way of provision of volunteerism hours and participation in fundraising events, is encouraged by the discretion of the Parent(s).
NOTES:
Terms and conditions of agreement between MHA and the Parent(s) or Guardian(s) of the enrolling child are bound by the Parent(s) Handbook as well as any other supplemental provisions.
A NON-REFUNDABLE REGISTRATION FEE MUST ACCOMPANY THIS APPLICATION
PERMISSION TO USE PHOTOGRAPHS OF CHILDREN FOR APPROVED NEWSPAPER AND MAGAZINE ARTICLES AND TV PROGRAMS
We hereby agree to allow newspaper, magazine and TV photographers, approved by Mount Hope Academy, to use, for publication, photographs taken of our child at Mount Hope Academy. We also agree to allow the staff of Mount Hope Academy to post photographs taken of our child on the Academy website and facebook page.
Child Name:______
Parent or Guardian Signature: ______Date: ______
ADDITIONAL REGUIRED FORMS
- Your child’s original birth certificate (we will copy and return the certificate).
- Physical examination by or under the direction of a physician before the child’s attendance or within one month after attendance. If the child has had a physical examination prior to attendance, it shall be within 12 months prior to attendance for children three years of age through five of age.
FOR OFFICE USE ONLY
Confirmation of receipt of required forms:
Enrollment Agreement: ____Child Health Record: _____
Consent for Emergency Treatment: ____ Medical Consent: _____
Allergy Release: _____
Permission to Use Photographs of Child Form: _____
Birth Certificate: ______
Initial Tuition Rate: $______/week
Sibling Discount: _____% $______/week
Child begins in: ______class
Advance Deposit Received: Yes No
Date Received: _____
Amount Received: _____