Livingston Academy
320 Huntington Street
Covington GA 30016
770-385-4008
Enrollment Form
Entrance Date______With drawl Date______
Child’s Name______Sex___ Age___ Date of birth______
Home address______
Parent/Guardian E- mail Address______
Mother’s Name______Mother home#______
Mother’s Physical Address______
Mother’s place of employment______
Physical address of employer______
Cell # ______Work #______EXT______
Father’s Name______Father home #______
Father’s physical address______
Father place of employment ______
Physical address of employer______
Cell # ______work# ______EXT______
Child’s Livings Arrangements (check one) ( ) Both parents ( ) Mother ( ) Father ( ) Other
Child’s Legal Guardian(s) (check one) ( ) Both Parents ( ) Mother ( ) Father ( ) Other
Child’s Primary care Physician:
______Phone number______
Physical address of Physician______
Name of school child attends: ______
Does your child have any known allergies? ( ) Yes ( ) NO
If yes please list ALL ALLERGIES:______
Does the child take ANY medications? ( ) Yes ( ) NO
Please list ANY & ALL medications prescribed for long-term continuous use that the child is currently on/prescribed. ______
Please list any pre-existing illness, and any health concerns:______
Please list any person the child may be released to (other than the parent)
Name ______Phone #______
Physical Address ______
Relationship to the child ______
Relationship to the parent/Guardian ______
Other identifying information (if any)______
Name ______Phone #______
Physical Address ______
Relationship to the child ______
Relationship to the parent/Guardian ______
Other identifying information (if any)______
Name ______Phone #______
Physical Address ______
Relationship to the child ______
Relationship to the parent/Guardian ______
Other identifying information (if any)______
** Please note any one picking up a child must present proper ID **
Are the child’s immunizations up to date? ( ) Yes ( ) NO
If no explain______.
My child has the following special needs ______
______.
Please list any physical problems, mental disorders, mental retardation and developmental disabilities that would limit the child’s participation in the center program activities.
______.
EMERGENCY CENTACT INFORMATION: This is someone to contact in an emergency, when a parent cannot be reached. The child may also be released to the emergency contacts you list.
Name______Phone #______
Physical address ______
Relationship to the child ______
Name______Phone #______
Physical address ______
Relationship to the child ______
Name______Phone #______
Physical address ______
Relationship to the child ______
EMERGENCY MEDICAL AUTHORIZATION:
Should (child’s name)______date of birth ______
Suffer an injury or illness while in the care of Livingston Academy and the facility is unable to contact me (us) immediately, it shall be authorized to secure such medical attention and care for the child as may be necessary. I (we) shall assume any and all responsibility for any payment for services received.
Parent/Guardian:
Please print name______Date ______
Signature ______
Livingston Academy Administrator/Director:
Signature______Date ______
Parent policy verification form:
Child’s name ______Date ______
Livingston Academy encourages parent participation in all activities. We love for parents to chaperone on a field trip’s as well as special events. Parents are encouraged to stop by at any time; you are welcome to come in for class parties or simply to read a short story to the class. The children light up when they see their parents in their class, and that makes is happy too. We have an open door policy. This means you have the right to enter the center at any time announced.
Livingston Academy will hold parent conferences throughout the year to inform parents of their child’s progress. At this time we will advise you of any concerns we have for your child as well as how the child’s progressing in the classroom. As a parent you do not have to wait until a scheduled conference to talk about your concerns. You are encouraged to speak to the director at any time, or as a concern may arise.
By signing below you are stating that you have read, received and understand the policies and procedures for Livingston Academy & that you will follow all rules as stated in the handbook.
Please review a few of important rules below that are also included in the hand book.
*We have a 9:30am cut off time; all children must be here by 9:30am in order to enter for that day. No children are permitted entry after 9:30am unless you have a doctor’s note and called ahead to make prior arrangements.
*NO CHILDREN ARE PERMITTED DROP OFF BETWEEN 11:00AM-2:00PM (this is lunch & nap time)
*FULL TUITION IS DUE NO MATTER IF A CHILD COMES ONE DAY, ALL WEEK, OR NO DAYS. You pay to hold a spot.
Mother’s Printed Name ______Date______
Signature______
Father’s Printed Name ______Date ______
Signature ______
Director Signature______Date______
Authorization to Dispense External Preparations
Parental authorization, except for first aid, personnel shall not dispense prescription or non-prescription medications to a child without a specific written authorization from the child’s physician or parent. Such authorization will include when applicable, the date, full name of the child, name of the medication, prescription number, if any; the dosage, and the dates to be given. The time of day, to be dispensed and the signature of the parent. (These forms are available at the front desk)
I give Livingston Academy, permission to apply one or more of the following topical ointments to my child ______in accordance with the directions on the label of the container.
_____ Baby wipes
_____ Band-Aids
_____ Neosporin or similar ointment
_____ Bactine or similar ointment
_____ Sunscreen
_____Insect Repellent
_____ Non- Prescription ointment (such as A&D, Destin, Vaseline)
_____ Baby Powder
Other (Please specify) ______
______
Parent/Guardian Signature Date
*Center should maintain this form in the child’s file.*
Transportation Agreement
This is to certify that I give Livingston Academy permission to transport my child,
______from Livingston Academy at 7:00a.m. and deliver them to ______Elementary School by 7:45 a.m.
In the afternoons pick up from ______Elementary School at 2:15pm and deliver to Livingston Academy by 2:45pm.
On the following days: (Please check all that apply)
_____Monday
_____Tuesday
_____Wednesday
_____Thursday
_____Friday
I will contact Livingston Academy if my child is picked up early from school or absent and will not need transportation to or from Livingston Academy. If I fail to contact Livingston Academy I will be charged a $10.00 fee per occurrence.
In the event Livingston Academy is not present to receive my child, the following procedures are to be followed:______
The location of ______Elementary school is approximately ______miles from Livingston Academy.
Signature of Parent/Guardian ______Date______
Parental Agreement
Livingston Academy agrees to provide care for my child,______Monday through Friday, each week during the hours of 6:00am until 6:30pm. From January through December. My child will participate in the flowing meal plan (circle all applicable meals & snacks)
( ) Breakfast ( ) Morning snack ( ) Lunch ( ) Afternoon snack
Before any medication is dispensed to my child, I will provide a written authorization, which includes: date, name of child, name of medication, prescription number if any, dosages, date and time of day medication is to be given. Medicine will be in the original container with my child’s name marked on it. My child will not be allowed to enter or leave the facility without being escorted by the parents or by a person authorized by the parents or facility personnel into the child’s classroom. I acknowledge it is my responsibility to keep my child’s records current to reflect any significant changes as they occur, ex. Telephone numbers work location, emergency contacts, child’s physician, child’s
health status, infant feeding plans, and immunization records etc.
Livingston Academy agrees to obtain written authorization from me before my child participates in routine transportation, field trips, special activities away from the facility, and water related activities occurring in water that is more than 2 feet deep.
- I authorize Livingston Academy to obtain emergency medical care for my child when I am not available.
- I have received a copy and agree to abide by all policies and procedures for Livingston Academy LLC,.
- I UNDERSTAND THAT Livingston Academy will advise me of my child’s progress and issues relating to my child’s are as well as any individual practices concerning my child’s special needs. I also understand that my participation is encouraged in facility activities.
- I understand that Livingston Academy reserves the right to disenrollment my child at any time without reason.
Parent Signature______Date ______
Director Signature______Date ______
Child/Parent/Center Behavior Agreement
Livingston Academy reserves the right to dis-enroll any child without reason at any time without notice. Livingston Academy takes disruptive behavior very serious and will do all that we can to meet each child’s needs while in our care. However if at any time your child places a burden on our facility, or our staff the child can and will be dis-enrolled. Below you will find a list of behaviors that are grounds for dismissal from our program. Please read and sign below.
FIGHTING:
1ST OFFENSE= written warning and review the policy
2nd OFFENSE= 3 day suspension from the program (full tuition still due)
3rd OFFENSE= Immediate disenrollment from theprogram.
DESTRUCTION OF OUR PROPERTY:
1ST OFFENSE= Talk with parents and parents are responsible for all damages and repair/replacement cost.
2nd OFFENSE =Disenrollment from the program & parents are responsible for all damages and repair/replacement cost.
INNAPPROPRIATE LANGUAGE:
1ST OFFENSE=Written warning
2nd OFFENSE= Talk with parents
3rd OFFENSE =1 Day suspension (full tuition still due)
BITING:
*If a child bites 5 times they will be suspended from the program for a 2 week period.
*If a child bites and the bite breaks skin=the child will be dismissed immediately from the program.
Parent Signature ______Date ______
Director Signature ______Date ______
Livingston Academy
CAPS PARENTAL AGREEMENT
RE: Any child/children who receive money on tuition for the CAPS assistance program.
*Regardless of when the CAPS portion is paid, the parent weekly responsibility portion of tuition is due every Friday for the upcoming week’s tuition. This is how we bill for all customers. If the parent portion of tuition is not paid by Tuesday of each billing cycle a $10.00 late fee will be charged.
*If at any time an account becomes 2 weeks due (This is the parent weekly tuition portion) then the child/children CANNOT RETURN until the balance is paid in FULL. Please note you may lose your child’s spot if this happens as we cannot hold spots and we are now on a waiting list.
* If your child is absent for an entire week, YOU THE PARENT ARE THEN RESPONSIBLE FOR THE FULL TUITION AMOUNT (YOUR PORTION+CAPS PORTION). This is because CAPS will not pay if your child is absent and full tuition is still due.
*Full tuition is due even when a child is absent. YOUR PORTION +CAPS PORTION YOU WILL BE RESPONSIBLE FOR BOTH!!
*We require a 2 week notice to withdraw from our program, if you fail to give a 2 week written notice you will be responsible for full tuition for any balance owed for the two weeks + any other balance.
Parent Signature ______Date______
Child’s Name ______
Director Signature ______Date ______