Little Feet Child Care

Misty M. Slater

10956 SW Bretton Ct

Tigard, OR 97224

Phone: 503.679.8539

Email:

ENROLLMENT APPLICATION

2012

Child’s Name:

Date of Birth:

Address:

Phone:

GUARDIAN INFORMATION

Guardian 1’s Name: Home Phone:

Address: Work Phone:

Cell Phone:

Employer:

Address:

Date of Birth:

Email:

Guardian 2’s Name: Home Phone:

Address: Work Phone:

Cell Phone:

Employer:

Address:

Date of Birth:

Email:

MEDICAL FORM

(FILE COPY)

Child’s Name: DOB:

Mother’s Name: Phone:

Father’s Name: Phone:

Insured Name:

Insurance Carrier: Policy #:

Doctor’s Name: Phone:

Address:

Dentist Name: Phone:

Our child care provider, MISTY SLATER has our permission for the following:

(please check all that apply)

to call an ambulance if necessary
to take our child to a physician or hospital in case of emergency
to give prescription medication when instructed as prescribed by child’s physician
to give non-prescription medication as instructed by parents
Tylenol
Motrin
Orajel
Teething tablets
Sunscreen (LFCC supplies Neutrogena Sunscreen)
Other Sunscreen (you must supply it)
Other (please specify)

I/We understand that any medical expenses necessary are my/our responsibility.

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SignatureSignature

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DateDate

MEDICAL FORM

(EMERGENCY COPY)

Child’s Name: DOB:

Guardian 1’s Name: Phone:

Guardian 2’s Name: Phone:

Insured Name: Policy #:

Insurance Carrier:

Doctor’s Name: Phone:

Address:

Dentist Name: Phone:

Our child care provider, MISTY SLATER has our permission for the following:

(please check all that apply)

to call an ambulance if necessary
to take our child to a physician or hospital in case of emergency
to give prescription medication when instructed as prescribed by child’s physician
to give non-prescription medication as instructed by parents
Tylenol
Motrin
Orajel
Teething tablets
Sunscreen (LFCC supplies Neutrogena)
Other Sunscreen (you must supply)
Other (please specify)

I/We understand that any medical expenses necessary are my/our responsibility.

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SignatureSignature

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DateDate

EMERGENCY RELEASE FORM

(EMERGENCY COPY)

Either a parent or a guardian, having legal custody of a minor, may give written authorization for an adult, into whose care the minor has been entrusted, to consent to x-ray examinations, anesthesia, medical or surgical diagnosis and/or treatment and hospital care to be rendered, to the said minor, under the provisions of the medical practice act, or to x-ray examinations, anesthesia, dental and/or treatment and hospital care to be rendered to said minor by a dentist licensed under the dental provisions law.

Child’s Name:

Child’s Doctor: Phone:

Child’s Dentist: Phone:

Insured Company: Policy #:

Guardian 1’s Name: Guardian 2’s Name:

Home Phone: Home Phone:

Work Phone: Work Phone:

Cell Phone: Cell Phone:

AUTHORIZATION

I ______and/or ______understand the above and hereby authorize Misty M. Slater , owner of Little Feet Child Care, LLC to give permission for any necessary medical, hospital or dental treatment for my child, ______in the event of injury or illness while the child is in care of the above name provider or center. I understand and agree that I would be financially responsible for any medical treatment necessary. I have full understanding that every attempt will be made to contact the parent/guardian in the even that medical treatment is necessary. I understand that certain medical emergencies may not allow much time for contact of the parent/guardian and that if a life threatening situation arises, immediate attention will be sought by the provider.

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SignatureSignature

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DateDate

EMERGENCY RELEASE FORM

(FILE COPY)

Child’s Name:

Child’s Doctor: Phone:

Child’s Dentist: Phone:

Insured Company: Policy #:

Guardian 1’s Name: Guardian 2’s Name:

Home Phone: Home Phone:

Work Phone: Work Phone:

Cell Phone: Cell Phone:

AUTHORIZATION

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SignatureSignature

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DateDate

HEALTH HISTORY

Child’s Name: Date of Birth:

Last Physical Exam:

**A COPY OF YOUR CHILD'S IMMUNIZATION RECORD FROM THE DOCTOR IS REQUIRED FOR YOUR CHILD'S FILE**

Vaccination / Dose 1 / Dose 2 / Dose 3 / Dose 4 / Dose 5
Diptheria/Tetanus
DTaP / 2 months / 4 months / 6 months / 18 months / 5 years
Polio
IPV or OPPV / 6 months / 9 months / 18 months / 5 years
Chickenpox
Varicella / 12 months / Booster
Measles/Mumps/Rubella
MMR / 12 months / 5 years
Hepatitis B
Hep B / 1 month / 2 months / 9 months
Haemophilus Influenza
Hib / 2 months / 4 months / 6 months / 15 months
Hepatitis A
Hep A
Pneumococcal
PCV7 (under 5) / 2 months / 4 months / 6 months / 18 months
Meningococcal
MCV7 (ages 11-18)
Tetanus/Diptheria
Booster / 12-15 years
Other:
Other:
Other:
Other:

Allergies:

Dietary Restrictions

Has your child been hospitalized? (explain)

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Has your child had injuries with fractures or loss of consciousness? (explain)

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PICK UP AUTHORIZATIONS

The following people listed below are allowed to pick up my/our child, , if instructed by the parent/guardian.

Name: Phone:

Additional Comments:

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IN CASE OF AN EMERGENCY

In case of an emergency, please contact one of the following if the parent/guardian cannot be reached.

Name: Phone:

PHOTOGRAPH RELEASE

I/We ______, give permission for Misty M. Slater or staff at Little Feet Child Care, LLC to photograph my child, ______. For the following purposes: (CHECK THOSE THAT APPLY)

Still Photographs
Display in Provider’s Scrapbook
Give Photo’s to current clients
Display on bulletin boards, shown to prospective Client’s
Use still photos in promotional materials
Upload to dropshots & snapfish for parents to print
Little Feet Child Care, LLC Website (children's names are not used on website)
Little Feet Child Care, LLC Facebook Page (children's names are not used on Facebook)

WATER RELEASE

I/WE give permission__I/WE do not give permission __ to Misty Slaterand staff of Little Feet Child Care, LLCfor my/our child to participate in water play (touch tub) or swimming activities (sprinklers) NO POOLS!

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SignatureSignature

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DateDate

TUITION CONTRACT

Child’s Name: Date of Birth:

I ______and/or ______are in agreement that, I/WE will pay $ per monthfor child care days per weektoLittle Feet Child Care, LLC. Payment is due at the beginning of the month. Payment is required in advance.

I/We understand that if our payment is received by provider, past the agreed upon payment date, we will be charged as follows: a late payment of $25.00 for each day the payment is late. In addition, I/WE understand and agree that an additional fee of $2.00 per minute will be charged if child(ren) are not picked up as agreed on this contract.

DAYS OF THE WEEKHOURS OF THE DAY

Monday7:00-5:30
Tuesday7:00-5:30
Wednesday7:00-5:30
Thursday7:00-5:30
Friday7:00-5:30

Additional Terms: Late fees will not apply if there are poor road conditions such as snow, ice, freezing rain, etc. If these are the conditions, please call to inform provider that you will be arriving late.

If provider should receive a check back, due to insufficient funds, there will be a fee of $35.00. Late payment and/or insufficient funds may result in termination of your child’s enrollment.

Should I/WE decide to discontinue child care services, I/WE will give 30 days notice. If 30 day notice is not given in writing, tuition will not be reimbursed for those days.

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SignatureSignature

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DateDate

CHILD CARE CLOSURES CONTRACT

I/We understand that the following days are paid closure days for Little Feet Child Care, LLC and are responsible for finding our own back child care if necessary.

2012 HOLIDAY AND VACATION CLOSURES

All Vacation Days And Holidays Are Paid

January 2012 No Closures

February 2012Monday, February 20th President’s Day

March 2012Mon-Fri, March 26th -30th Vacation

April 2012No Closures

May 2012Monday, May 28thMemorial Day

June 2012No Closures

July 2012Wednesday, July 4th Independence Day

Mon-Fri, July 9th - 13th Vacation

August 2012Monday, August, 27thVacation

Friday, August 31stVacation

September 2012Monday, September 3rdLabor Day

Friday, September 21stVacation

October 2012No Closures

November 2012T, F November 22nd - 23rd Thanksgiving

December 2012Mon-Fri, December 24th - 28th Vacation

Monday, December 31stNew Year's Eve

January 2013Tuesday, January 1stNew Year's Day

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ADDENDUM 2

ANNUAL ENROLLMENT FEE

The $100.00 annual enrollment fee is due prior to your child’s first day and January 1st every year after. The fee helps to cover state required registration, training and licensing. However, if you enroll in the fall, you will not accrue another enrollment fee in January. Your next enrollment fee will not come due until the following January. For multiple children, the fee is $100.00 for the 1st child and $50.00 for each additional child.

Example: Child A is enrolled in September 2011 and a $100.00 fee is charged. January 2012 arrives and the $100.00 enrollment is waived. The next enrollment fee is due January 2013.

SignatureSignature

DateDate

ADDENDUM 3

DISCIPLINARY GUIDELINES

Little Feet Child Care, LLC follows the following guidelines for and not limited to…

Biting

Hitting

Kicking

Inappropriate Language

Any behavior which endangers the child(ren), teacher or environment

IDENTIFY-the inappropriate behavior
DOCUMENT-behavior, time of incident, place, activity occurring, including staff and director signatures
INFORM-parent (verbally and written, requiring parent signature)
OBSERVE-the environment, schedule, child/child interaction, developmental stages, staff/child interaction
CONFERENCE-with parent(s), teacher and director
PLAN OF ACTION-developed with developmentally appropriate practices as a guideline, in conjunction with parent(s) and facility input. Including responsibilities of each party, time frame and date of follow up with the understanding that any inappropriate behavior can and will necessitate immediate response which could occur prior to scheduled follow up conference
FOLLOW UP AND OBSERVATION-track either successful improvement or any continuation of the inappropriate behavior
COMMUNICATE-with parent(s) concerning observation. Could require development of an additional action plan and/or request for alternative care

If the inappropriate behavior persists and/or the behavior is demonstrated routinely, Little Feet Child Care, LLC reserves the right to request that alternative care be provided which can include one or all of the following: removal from daycare on the day of the incident, brief request of absence from daycare, or dis-enrollment.

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SignatureSignature

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DateDate

ADDENDUM 1

(YOUR COPY)

2012 HOLIDAY AND VACATION CLOSURES

All Vacation Days And Holidays Are Paid

January 2012No Closures

February 2012Monday, February 20thPresident’s Day

March 2012Mon-Fri, March 26th -30thVacation

April 2012No Closures

May 2012Monday, May 28thMemorial Day

June 2012No Closures

July 2012Wednesday, July 4th Independence Day

Mon-Fri, July 9th - 13thVacation

August 2012Monday, August, 27thVacation

Friday, August 31stVacation

September 2012Monday, September 3rdLabor Day

Friday, September 21stVacation

October 2012No Closures

November 2012T, F November 22nd - 23rdThanksgiving

December 2012Mon-Fri, December 24th - 28th Vacation

Monday, December 31stNew Year's Eve

January 2013Tuesday, January 1stNew Year's Day

Enrollment 2012