Forms

Art Barn Contract 

This agreement is made by and between Rosemary Igoe Coyle, Licensed Child Care Provider and _______________________, Parent/Guardian of ________________. The following has been agreed upon between the two parties beginning _____________:

I am enrolling my child at Art Barn as of ____________.  Tuition to be paid on the first of the month in advance.  Art barn is open for  September through June  .  We are open during Christmas, February and April vacations.  We are closed on Major holidays.

Art Barn is open Monday thru Friday from 7 30am until 3 30pm. Special accommodations can be made for families who need slightly different hours.    Arrival time and departure times are at the parents discretion with notice given to Miss Rose when possible.

These are the hours agreed upon:  arrival_______ departure_______ daily rate_____

Days my child will attend  M. T, W, TH, F (please circle)

Any added time before or after these hours will be discussed and negotiated beforehand.

Tuition to be paid on the first of the month in advance.

There are no refunds given for days missed and hours are only interchangeable if the schedule allows.

Art barn is open September through June,.  We are open during Christmas, February and April vacations.  We are closed on Major holidays. Tuition is  charged for holidays. Miss Rose may take up to 3 paid sick  days.  These will only be used in extreme circumstances.  Parents will be given as much notice as possible.  Make up days will be offered as the schedule allows.

A late fee of $25 dollars will be assessed after the 10th of the month

One Months deposit is required to hold a spot.  This shall be applied as last months tuition.  30 days notice is required to terminate contract.

This agreement shall be in effect until which time parent/guardian or provider has given termination notice in accordance to the Parent Handbook policy, or negotiation of a new contract.

___________________________________ ________________

Licensed Child Care Provider Date

BOTH PARENTS MUST SIGN OR PARENT/GUARDIAN WITH SOLE CUSTODY OF THE CHILD:

___________________________________ ________________

Parent/guardian Date

___________________________________ ________________

Parent/guardian Date

Permission to use photos

You may/may not use my child’s photo in newsletters, on the website and on posters.  

________________________________________________

Enrollment forms

General Information

Date of admission_____  Date of discharge

Childs full name__________________   Date of Birth______________________

Address_________________________________City_______________ State_____zip____________

Telephone numbers______________________   ________________________

email address_____________________________________

Physical description

eye color_______hair color___________ height_______________weight_____________sex_________

other distinguishing characteristics____________________

Parent /guardian info during child care

name______________address_______________phone __________________email_______________

name_____________address________________phone__________________email________________

Emergency Contacts (In order to be contacted

Name_______________________________________________________________________ Address_____________________________________________________________________

Relationship to child____________________________________________________________

Home Phone__________________________ Cell Phone______________________________

Do you give permission for child to be released to this person? Yes_____ No______

Name_______________________________________________________________________ Address_____________________________________________________________________

Relationship to child____________________________________________________________

Home Phone__________________________ Cell Phone______________________________

Do you give permission for child to be released to this person? Yes_____ No_____

Name_______________________________________________________________________ Address_____________________________________________________________________

Relationship to child____________________________________________________________

Home Phone__________________________ Cell Phone______________________________

Do you give permission for child to be released to this person? Yes_____ No___

Transportation plan to and from Art Barn

Please specify the usual plan for drop off and pick up ___________________________________________________________________________________

 

DEVELOPMENTAL HISTORY AND BACKGROUND INFORMATION

CHILD’S NAME_______________________DATE OF BIRTH___________________

PERSONAL HISTORY

Any speech difficulties?__________________________________________________

Language spoken at home:_______________________________________________

Special words to describe needs:__________________________________________

HEALTH

Special physical conditions and disabilities: _________________________________

Allergies: ____________________________________________________________

Regular medications: ___________________________________________________

EATING HABITS

Describe favorite foods, foods refused, and any special characteristics: ____________

TOILET HABITS

How does child indicate bathroom needs include any special words): ______________

_____________________________________________________________________

SLEEPING HABITS

When does child get up in the morning: ___________and go to bed at night_________

Does child become tired or nap during the day?_______________________________

SOCIAL RELATIONSHIPS

How would you describe your child: ________________________________________

Previous experience with other children:_____________________________________

Reaction to strangers:_______________________ Able to play alone: ____________

Favorite toys and activities: _______________________________________________

_____________________________________________________________________

Fears (the dark, animals etc.):_____________________________________________

How do you comfort child: ________________________________________________

How do you discipline child: ______________________________________________

What would you like your child to gain from this experience?

Is there anything else you would like us to know about your child?

Parent’s signature___________________________  Date: _____________________

EMERGENCY CARD INFORMATION

Child’s Name: ______________________________Date of Birth_________________

Child’s Home Address: __________________________________________________

____________________________________ Phone # _________________________

Mobile Phone #________________________ E-mail___________________________

–INSTRUCTIONS TO REACH PARENT/GUARDIAN–

1.___________________________________________________________________

(Name, Address, Phone #)

2.___________________________________________________________________

(Name, Address, Phone #)

PEDIATRICIAN or SOURCE OF HEALTH CARE

  1. ________________________________________________________________ (Doctor’s Name, Address, Phone #)

–MEDICAL EMERGENCY TREATMENT–

I hereby give   Art Barn preschool

permission to administer basic first aid and/or CPR to my child________________

(Name)

and/or take my child __________________, to a hospital for medical treatment

(Name)

when I cannot be reached or when delay would be dangerous to my child’s health.

_____________________________ __________________________

(Parent Signature)(Date)

Insurance Information (Optional)

Company Name:_____________________ Policy # ________________________

Participating Hospital: ________________________________________________

Special Instructions:_________________________________________________

THE COMMONWEALTH OF MASSACHUSETTS

Department of Early Education and Care

FIRST AID AND EMERGENCY MEDICAL CARE CONSENT FORM

Child’s Name: _______________________________ Date of Birth: ___________________

I authorize staff in the child care program who are trained in the basics of first aid/CPR to give my child first aid/CPR when appropriate.

I understand that every effort will be made to contact me in the event of an emergency requiring medical attention for my child. However, if I cannot be reached, I hereby authorize the program to transport my child to the nearest medical care facility and/or to ________________________, and to secure necessary medical treatment for my child.

Child’s Physician Name: ________________________________________________________

Address: ____________________________________________________________________

Phone Number: _______________________

Child’s Allergies: ______________________________________________________________

Chronic Health Conditions: ______________________________________________________

Physical examination  

Evidence of a physical exam invalid for one year from the date the child was examined and must be renewed annually thereafter.

Please provide documentation of a physical exam provided by your childs’  doctor including lead testing, and a record of immunizations.

Visits

Please sign to indicate that you are aware that you are welcome to visit Art Barn at any time your child is in my care.________________________

Parent Handbook 

Please sign to indicate that you have read and accept the terms of the parent handbook  ________________________

Advertisements

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s