Learning Center Enrollment Form Use this form to being the enrollment process for any of Early Childhood Alliance's Learning Centers. Step 1 of 7 14% Start Date* Date Format: MM slash DD slash YYYY Location*Beacon Learning CenterDowntown Learning CenterChild Care Hours NeededApproximation is fineFrom* : HH MM AM PM To* : HH MM AM PM Days care is needed* Select All Monday Tuesday Wednesday Thursday Friday Primary Contact 1Name* First Last Relationship to childrenAddress* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code County of Residence*School System*Cell Phone Number*So that we may send special announcements via text message.Cell Phone Carrier*So that we may send special announcements via text message.Phone Number For Emergencies*Email* Date of birth* Date Format: MM slash DD slash YYYY Marital Status*MarriedDivorcedSeparatedSingleEmployer/School*Please provide the name of your or employer or school.Employer/School Phone Number*Employer/School Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Work/School Hours Begin* : HH MM AM PM Work/School Hours End* : HH MM AM PM Work/School Days* Select All Monday Tuesday Wednesday Thursday Friday Primary Contact 2Name First Last Relationship to childrenAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code County of ResidenceSchool SystemCell Phone NumberSo that we may send special announcements via text message.Cell Phone CarrierSo that we may send special announcements via text message.Phone Number For EmergenciesEmail Date of birth Date Format: MM slash DD slash YYYY Marital StatusMarriedDivorcedSeparatedSingleEmployer/School*Please provide the name of your or employer or school.Employer/School Phone Number*Employer/School Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Work/School Hours Begin : HH MM AM PM Work/School Hours End : HH MM AM PM Work/School Days Select All Monday Tuesday Wednesday Thursday Friday Child InformationChild's Name* First Last Child's Birth Date* Date Format: MM slash DD slash YYYY Child's Gender*FemaleMaleChild's Legal Guardian's Name* First Last Child Lives With* Primary Contact 1 Primary Contact 2 Other Doctor's Name* First Last Doctor's Phone Number*Dentist's Name* First Last Dentist's Phone Number*Hospital Preference*Allergies/Food SensitivitiesSpecial NeedsName of person child lives with and their relationship*You selected "other" in the previous question, please provide some additional details.Does This Child Have Any Special Needs?*If you select "Yes" documentation must be provided to Early Childhood Alliance (i.e. IEP, ISTAR, IFSP)YesNoIdentified special needs of your child*Who identified these special needs?*Is there any family participation in other services?* First Steps Healthy Families Other You selected "Other" for services, please describe the service*How often do you participate in the aforementioned services?*Getting Acquainted With Your ChildSiblingsClick the + symbol to enter additional siblings.NameAge How often does your child see their non-custodial parent?*What would you like us to know about your child's cultural background?*Does your child take medication regularly?*YesNoWhat medications and for what reasons*Please list any health problems or special needs if applicableAny other information we should know in order to help us know your child better?(i.e. tubes in ears, etc.)Is this child an infant?*YesNoHas your child experienced group care before?*YesNoWhere have they experienced group care before?*When did they experience this group care?*When is the child's first nursing?* : HH MM AM PM Reason for leaving previous group care?*What three words best describe your child?*Favorite play materials/special interests*Pets*Is the child nursed in an hourly interval or on demand?*Hourly intervalOn demandWhat interval is the child nursed?*Is your child nursed with breast milk or formula?*Breast MilkFormulaBothName of formula*How many ounces of formula per feeding?*Formula feeding intervals*Comfort Needs*Sleep Patterns*Way to be held to be put to sleep, calmed, or when fussyWhat does your child like to eat?*Does your child feed him/herself?*YesNoDoes your child have any food dislikes?*What time does your child go to bed?* : HH MM AM PM What time does your child get up from bed?* : HH MM AM PM Does your child nap?*YesNoHow long does your child nap for?*What time does your child usually take a nap?* : HH MM AM PM Does your child have a special toy to nap with?*What is your child's routine in preparation for rest?*(i.e. story time, quiet play, snack)Is your child toilet trained?*YesNoWhat is the normal number of bowel movements your child has daily?*Does your child use the toilet on his/her own?*YesNo, they tell an adult firstDoes your child need to be reminded to use the toilet?*YesNoAt what time intervals should your child be reminded to use the toilet?*Does your child need help with clothing?*YesNoDoes your child have certain words to indicate a need to use the toilet/bathroom?*Please list any fears your child hasIf you have additional children you need to enroll, we'll gather their information when you come in. Authorized Pick-Up ListPickup 1 Name First Last Pickup 1 Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Pickup 1 PhonePickup 1 Relationship to childPickup 2 Name First Last Pickup 2 Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Pickup 2 PhonePickup 2 Relationship to childPickup 3 Name First Last Pickup 3 Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Pickup 3 PhonePickup 3 Relationship to childPickup 4 Name First Last Pickup 4 Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Pickup 4 PhonePickup 4 Relationship to child Household InformationPrimary Language in Household*Mother's Education Completed* High School Some College Associate Degree Bachelor's Degree Master or Higher Father's Education Completed* High School Some College Associate Degree Bachelor's Degree Master or Higher Holiday QuestionnaireChildren in our program come from many different backgrounds and cultures, and celebrate different holidays and traditions. Religion plays an important role in many of these holidays. While considering the following question, please keep in mind that teachers would not teach any religious perspective as the "right" religion, rather we would always say, "Some people believe..." or "At Sally's house, they believe..." Your answer to this question will help us respect your family's beliefs and traditions while planning our holiday activities. Are there any holidays that you do not wish your child to take part in while in our care?*No objections. My child may participate in all holiday activitiesI object to the following holidays...Please specify which holidays you object to* Parent OrientationEarly Childhood Alliance Centers are open Monday through Friday, 6am-6pm. We are closed on all the major holidays: New Year's Day, Good Friday, Martin Luther King Jr. Day, Independence Day, Labor Day, Thanksgiving Day and the day after Thanksgiving, Christmas Eve, Christmas Day, and some days during Christmas and New Year's week. We are also closed for two annual Professional Development days - one in February and one in August. Check the following boxes to signify that you understand and agree to corresponding statements.Scheduling* We must have an emergency telephone number for parents while their children are in our care. Whenever parents are not at work, they need to notify us of an emergency number where they can be reached, and at least one alternate emergency number.Arrival & Departure* To benefit from our educational curriculum, consistency is important. Therefore, children should arrive at the Center by 9:30 amArrival & Departure* I will escort my child into the classroom and inform the classroom teacher when my child arrives and leavesArrival & Departure* Parents are asked to not use their cell phone at drop or pick up time. Teachers would like to use this time to exchange information about your child.Arrival & Departure* I will notify the Center Manager if my child is to be absent for any reason.Arrival & Departure* Children will only be released to their parents/guardians or authorized adult.Authorized pickups must be established with Center office staff before they will be permitted to enter the classroom areas or allowed to pick up a child.Arrival & Departure* I understand that if a staff person is concerned about the safety of my child at pick-up time because I or an authorized adult seem disoriented/impaired judgement, that staff person has the right and responsibility to call an emergency contact. If attempts to keep the child safe from disoriented authorized adult are unsuccessful, then the Police Department will be contacted.Arrival & Departure* Parents are asked not to allow older siblings into infant/toddler classrooms for the health and safety of infants/toddlers.Personal Belongings* The Child Care Center will provide all food, play, and learning materials.Personal Belongings* Parents are asked to bring five (5) complete changes of appropriate play clothing for their children.Children go outside every day when the temperature is above 25 degrees, including the wind chill factor. Be sure to include hats, boots, mittens, etc. on colder days. Personal Belongings* All clothing should be visibly marked with the child's name.Personal Belongings* Soiled clothing will be put in a plastic bag and placed in the child's cubby.Parents are asked to pick up these bags at the end of every day.Personal Belongings* Children are asked to bring a small blanket/cover to use at naptime and may bring a special comfort item (i.e. stuffed anmial)These items must all fit in the child's cubby.Personal Belongings* We ask that all other toys be left at home to eliminate lost or broken toys.Early Childhood Alliance will not be held accountable for broken or lost toys that are brought from home.Personal Belongings* Due to limited space, all strollers, diaper bags, etc., need to be taken with you and not left at the Center.Dress Code* Ensure that your child is dressed in appropriate and safe attire.Children spend part of their time engaged in outdoor activities.Dress Code* Open-toed sandals, flip-flops, and strapless shoes are not allowed at any time.Dress Code* Open-toed sandals, flip-flops, and strapless shoes are not allowed at any time.Food/Nutrition* We are a peanut-restrictive CenterFood/Nutrition* Children requiring special diets (i.e. allergies, food sensitivities, supplements, or other changes outside state guidelines) need a note from their physician and applicable completed documentation.The doctor's note must be updated annually. Special considerations are made for religious reasons. This, too, requires documentation from a parent and parents are requested to provide special foods. A meeting may be required to ensure needs are being met.Food/Nutrition* A feeding plan signed by a physician is required for all infants.Changes to feeding plans outside the state guidelines will be done only in written order from the child's doctor.Food/Nutrition* Treats brought in for special holidays or occasions must be commercially prepared and in unopened packaging.We are unable to serve homemade products. Please bring nutritional items on the enclosedIllness & Medication* Keep your child at home when symptoms are present that are included under "Illness" in the Parent Handbook.Illness & Medication* Children that fall ill will be isolated from other children.If needed, he/she will be supervised, and the parent will be called. You will receive an illness report that will inform you of your child's symptoms, action taken by the teacher, and when your child may return to the Center. Illness & Medication* Every attempt should be made to pick up an ill child within 1-hour of being notified.It is the parent or legal guardian's responsibility to secure alternative child care arrangements for an ill child.Illness & Medication* You are required to notify the Center Manager if your child has been ill or exposed to a contagious disease.Children with a fever, rash, or other condition that prevents them from participating in Center activities will not be permitted to attend. Illness & Medication* You will be notified if your child becomes ill or has an accident while at the Center.In the case of accidents, immediate first aid will be given but further treatment will be the responsibility of the parent.Illness & Medication* Children must be symptom free without the aid of fever reducers before being permitted to attend the Center.Symptoms must be absent for a period of 24 hours or more.Illness & Medication* You will be notified of any significant exposures which may affect your child.This may include potential exposure to a communicable disease, head lice, etc.Illness & Medication* Prescription medications must be prescribed by a physician and brought to the Center in pharmacy labeled containersParents must complete the medication form in the classroom. Non-prescription medications can be given, providing a parent/guardian submits a written order from their physician.Discipline* The goal of our Center is to provide a positive environment in which children can succeed.We accomplish this with redirection, problem-solving, and conflict resolution. In cases of continued negative behavior, a plan of action will be created with parents and staff.Discipline* Any disciplinary action taken will be reported to me and noted in my child's recordDiscipline* If your child cannot adjust to the program because of social, physical, or emotional problems, after a reasonable trial period and/or plan of action, the agency will help in making an appropriate referral or placement, and I will find other care for my child.Health & Safety* A physical examination and necessary immunizations are required for enrollment.These must be completed before your child can begin attending and must be kept up-to-date.Health & Safety* Your child's file must always be complete and regularly updated.Health & Safety* Infant classrooms follow a strict, no-shoe policy.You are asked to remove your shoes or place a foot covering over them before you enter the classroom.Miscellaneous* There will be at least two scheduled conferences with your child's teacher.But you can request a conference at any time.