ENROLLMENT APPLICATION


* = Required Information
Yes No
Private Pay Voucher Program Both

Hours Of Care?

Mon Tue Wed Thurs Fri

Mother Father Both Other

If Applicable


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If you receive our Policy & Procedure & reviewed Disciplinary Procedure Portion?

Yellow Pages
Search Engine (Example Google etc)
Friend
News Article
Passing By
Other

Updated Physical Record

Updated Immunization Record

Child’s Birth Certificate

Park Permission Slip


Office used only ( assigned payments )







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

Yes No
Yes No
Yes No
Yes No

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 application.

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

Yes No

I authorize all of the above.

PERMISSION SLIP



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.)

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, (WWW.ATENDERYEARS.COM).

** 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 )

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 labelled 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.
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