Rev 4/13 & 6/16

TENDER YEARS CHILDCARE, INC.

3141 E. Tremont Ave. Bx. /Have Questions? Speak to Mr. Ruben & to reach your child’s teacher 718 829-3067

GENERAL ADMISSION / ENROLLMENT APPLICATION

First Name ______Last Name ______

Email Address ______Cell Number______

Home Number ______Work Number ______

Child’s date of birth_ /_ /_

Date like to enroll _ /_ /_

Looking for full time schedule Yes __ No __

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Part Time - Provide us the different schedules you would like us to check availability and rates.

Schedule 1 ______

Schedule 2 ______

Schedule 3______

Are you paying out of pocket? Yes __ No __Do you have a voucher? Yes __ No __

Has the city agency told you to look for a child care during the interview? Yes __ No __

Are you transferring your child from another school? Yes __ No __

If so, please tell us the name of the daycare. ______

Any questions, suggestions or concern you like to share with us?

______

2

AUTHORIZE AND EMERGENCY PICKUP - CONTACT INFO.

Child will be released only to the custodial parent or legal guardian and the persons listed below. The following people will also be contacted and are authorized to remove the child from this facility for normal pickups & in case of illness, accident or emergency, if for some reason, the custodial parent or legal guardian cannot be reached: Its imperative you keep us update with current contact information at all times. Please do not add any name already listed in applc.

PICTURE # 1

1) ______

(NAME)

______& D.O.B ______

(RELATIONSHIP TO THE CHILD)

______

HOME/CELL #)

______

(WORK#)

PICTURE # 2

2)______

(NAME)

______& D.O.B.______

(RELATIONSHIP TO CHILD)

______

HOME/CELL #)

______

(WORK#)

PICTURE # 3

3)______

(NAME)

______& D.O.B ______

(RELATIONSHIP TO CHILD)

______

HOME/CELL #)

______

(WORK)

Anyone you DO NOT give PERMISSION to pickup? Name ______

Medical Info. – I hereby grant permission to T.Y. staff to contact my child’s Doctor if incase of an emergency the hospital treating my child requests my child’s medical history.

Doctor______Address______Phone#______

ALLERGIES/ILLNESS ____ YES _____NO / IF YES, PLEASE EXPLAIN______

______

I authorize all of the above. Parent/Guardian Signature x______

Revised 3/1/12

TENDER YEARS CHILDCARE, INC.

3141 E. Tremont Ave. Bronx, NY 10461 / Direct all Questions or Concern to Mr. Ruben 718 829-3067

PERMISSION SLIP

Today’s Date ____ / ____ / _____Child’s Name______

Print Parent (Guardian’s) Name ______

Permission To Participate in Special Events/Activities

I hereby grant permission for the staff of this facility to take my child to the following events/activities.

School Trips Announce To Parent Prior, Nature Walks, Playground (private) including Participation in all Recreational Activities which involves active physical play.

I understand that Tender Years will have these outings as often as possible. ( weather permitting.)

Guardian Signature: x ______

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Permission to Advertise Your Child’s Picture

I hereby grant permission for the staff of this facility to have his/her picture taken only for T.Y. advertisement use and for the customizing of our Website, (

Parent Signature: X______

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** IN THE EVENT OF AN EMERGENCY,**

I HEARBY GRANT PERMISSION FOR THE STAFF OF THIS FACILITY AND, TO DOCTOR, OR HOSPITAL TO GIVE ANY AND ALL TREATMENT TO MY CHILD IF AND WHEN IS NECESSARY.

This agreement will take effect in the event I the parent can’t be contacted by phone or relative to notify me of an emergency incident. (For your peace of mind staff members in T.Y. have been certified in 1st Aid & CPR )

Guardian Signature ______

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AUTHORIZATION FOR MEDICATIONS

I hereby grant permission for the staff of this facility to minister my child Prescribed MEDICATION(s) in its container by my child’s Doctor. I understand that the medication must be labeled with the Doctor’s instructions or have a letter from the Doctor explaining how to minister the medicine to my child. If my child suffers of an illness my child’s Doctor must explain when G.C is to minister the medicine and when I should simply be called to pick up my child for further action regarding illness. Otherwise, I understand that Tender Years Childcare may not allow my child in school if these terms are not met.

Guardian’s Signature x______