Enrollment Application .pdf

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Original filename: Enrollment_Application.pdf
Author: Roots & Wings

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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.


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