Enrollment Application

Enrollment Form Roots and Wings Learning Center 210 Commerce Lake Drive Saint Augustine, FL 32095 (904) 940-9410 Date of Birth Sex Date of Enrollment Primary Hours of Care Child Information From: Last Name First Name MI Child’s Address City Zip To: Nickname Child Lives With L Family Information Social Security # Relationship to Child Address City Zip Home Phone Cell Phone Employer Last Name First Name Drivers License # Relationship to Child Address City Home Phone Cell Phone Employer Work Phone Social Security # Zip Work Phone Custody • Mother Father Both Other C Medical Information Phone Number Child’s Dentist Address Phone Number Hospital Preferences Allergies, special medical or dietary needs or other areas of concern Tuition: $_________ OFFICE USE ONLY Registration: $_________ Billing cycle: ____________ Door / ID Code: ________ Contacts _____________________ Program: ________________ Emergency Classroom:  Child will be released only to the custodial parent or legal guardian and the persons listed below. The following people will be contacted and are authorized to remove the child from the facility in case of illness, accident or emergency, if for some reason the custodial parent or legal guardian cannot be reached. Name Address Contact Number Name Address Contact Number Name Address Contact Number Name Address Contact Number Name Address Contact Number Helpful Information About Child Section 65C-22.006(2), F.A.C., requires a current physical examination (Form 3040) and immunization record (Form 680 or 681) within 30 days of enrollment. Section 402.3125(5), F.S., requires that parents receive a copy of the Child Care Facility Brochure, “KNOW YOUR CHILD CARE FACILITY” Section 65C-22.006(4)(c)2., F.A.C., requires that parents are notified in writing of the disciplinary practices used by the child care facility. Influenza Virus Brochure (DCF licensing requirement) By signing below, you verify that you have received the above items and that all information on this enrollment form is complete and accurate. __________________________________________ Signature of Parent/Guardian ___________________ Date Note: Please keep Roots & Wings Learning Center updated if any of the above information changes. ENROLLMENT AGREEMENT  Registration / Supply Fee A registration/supply fee of $100.00 is due upon enrollment. This is an annual, non-refundable fee. This fee is utilized for your child’s equipment and supplies for the year. ________ (initials) Weekly Tuition Fees A weekly tuition fee is due for__________________________, and is $__________. Tuition is due EVERY FRIDAY for the COMING WEEK. Payments not received by close on MONDAY will be subject to a $5.00 per day late fee. If payment is not made by close of Monday (6:00pm), of the current week, your account will be subject to $10.00 a day late fees and we reserve the right to deny admission until your account is current. ________ (initials) Late Pick-Up The hours of operation at Roots and Wings Learning Center are: Monday – Friday, 7:00am-6:00pm by the COMPUTER CLOCK! Late pick-up fees will be charged as follows for children not picked up on time: $5.00 for the first minute and $1.00 each additional minute/per child picked up after 6:00pm. ________ (initials) Vacation or Absence Weekly tuition is due in full every week that your child attends. If your child is absent partial weeks for any reason, tuition remains the same. You will receive 1 week credit per school year (August 25-July 31st ) FREE. You will need to pay the full cost of any additional weeks your child is absent to keep his/her space. ________ (initials) Withdrawals If for any reason you withdraw your child(ren) from Roots and Wings Learning Center, a two weeks WRITTEN NOTICE is required and tuition is due and payable for those two weeks whether or not your child attends. Tuition will be charged until such notice is given. ________ (initials) Parent Name Parent Signature Date   EMERGENCY RELEASE FORM I , , give permission for to provide First Aid/CPR for my child . Emergency Information Address Ph Phone Number In the case of an emergency I give permission to take my child to (hospital name) .  If my child need’s to be transported by an ambulance service please use . I understand all procedures and have given consent on all areas listed. Parent Name Parent Signature Date Photograph / Video Consent I , , give Roots & Wings consent to photograph or videotape my child, .I understand that these pictures and videos will not be used in any other means than to show the growth, development and the enjoyment that my child has at Roots & Wings Learning Center. These pictures and videos will not be given to  anyone but be used solely for Roots & Wings and its website. I , give Roots & Wings consent for my child , to watch videos that relate to an activity or subject talked about in class. Parent Name Parent Signature Date Child’s Biography Child’s Disposition H does your child react when you leave him/her? ______________________________________ What is your child’s normal disposition? ________________________________________________ Does your child have any bad habits? _______ If yes, what are they? _________________________ ___________________________________________________ Are there any restrictions to play or activities? ______ If yes, what are they? ___________________ _______________________________________________ Any speech, hearing or vision problems? _______ If yes, which one(s)? _______________________ _____________________________________ Is your child prone to any illness (such as headaches, tummy aches, etc.)? ______ If yes, what are they? ___________________________________________________________________ How is your child most easily settled? ___________________________________________________ Sleeping child’s mood when they are put to bed? _______________________________________ What is your child’s mood when they wake up? ___________________________________________ W yo  Does your child take a nap? _______ If yes, when? ___________________________ Personality Traits H ch experience playing with other children? ________ How does your child show when he/she is: Afraid? ____________________________________________________________________________ Happy? ____________________________________________________________________________ Angry? ____________________________________________________________________________ Tired? ____________________________________________________________________________ Toilet Training toilet trained or in the process? _______ If yes: What are the steps you are using to toilet train your child? ____________________________________ ___________________________________________________________________________________ Does your child have any fears relating to potty training? ________ Does your child have any accidents? ________ What word does your child use for: Bowel movements? ___________________ Urination? _____________________ Soiled Diaper? _______________________ Is ch     2011-2012 School Closures Monday, September 5, 2011 Labor Day – Holiday Friday, October 7, 2011 - Annual Teacher Conference *****Wednesday, November 24, 2011 – Open 7:00 – 3:00 Thurs. & Fri., November 24 & 25, 2011 Thanksgiving Break – Holiday *****Friday, December 23, 2011 – Open 7:00 – 3:00 Monday, December 26, 2011 Christmas – Holiday *****Friday, December 30, 2011 – Open 7:00 – 3:00 Monday, January 2, 2012 New Year’s Day – Holiday Monday, January 16, 2012 Martin Luther King – Holiday/Teacher Inservice Day Monday, February 20, 2012 Presidents’ Day – Holiday Friday, April 6, 2012 Good Friday – Holiday Monday, May 28, 2012 Memorial Day – Holiday Wednesday, July 4, 2012 – Holiday/Teacher Inservice Day Please Note:  We follow all weather related school closures for St. John’s County.  This School Closure schedule is subject to change.