enrollment

Enrollment form

Discovery Learning Center START DATE______________DIS-ENROLL DATE________________

FILE UPDATE:__________ / __________ / __________ / __________

______________________________________________________________________________________________________

Last Name,

First,

Date of Birth

Sex: M / F

______________________________________________________________________________________________________

Last Name,

First,

Date of Birth

Sex: M / F

______________________________________________________________________________________________________

Last Name,

First,

Date of Birth

Sex: M / F

_____________________________________________________________________________________________________

Street Address

City

State

Zip Code

Home Telephone

Additional Schools/Programs attending while enrolled and grade:____________________________________________

With whom does the child live? Both Parents______Mother______Father______Other______

Father/Guardian Information

Mother/Guardian Information

_____________________________________________ ________________________________________________

Last Name,

First

Last Name

First

_____________________________________________ ________________________________________________

Street Address

_____________________________________________ ________________________________________________

City State Zip Code

_____________________________________________ ____________________________________________

Home Telephone

_____________________________________________ ____________________________________________

Place of Work

_____________________________________________ ____________________________________________

Work/Daytime Telephone

_____________________________________________ ____________________________________________

Cellular Telephone

_____________________________________________ ____________________________________________

Email Address

Please list two people locally who we could call on to be responsible for your child in the event of an illness, accident or

emergency, if neither parent/guardian can be reached. These individuals are also authorized to pick-up the child, if the parent is unable to be contacted:

_____________________________________________________________________________________________________

Name Street Address

____________________________________________________________________________________________________

City, State Zip Code Daytime & Evening Telephone

_____________________________________________________________________________________________________

Name Street Address

_____________________________________________________________________________________________________

City, State Zip Code Daytime & Evening Telephone

We require written permission or a phone call by a parent/guardian prior to releasing any child from our facility. (*The

child will be released to both parents unless appropriate legal paperwork is on file, and the custodial parent has made

an alternate request in writing.) We will require a photo ID for anyone picking up the child that normally does not.

ex: Grandma,Aunt, or friend.

Please list people that are not allowed to pick up child and turn in any necessary documents.

________________________________________________________________________________

I,__________________________________________________, being the natural parent or legal guardian of

(Child)______________________________________________________hereby give my permission for my child to be

given emergency treatment to include first aid and/or CPR by a trained and qualified staff member of Discovery Learning Center and/or local fire department, EMT. I will not hold Discovery Learning Center liable for any injuries that result from trying to ressessitate or help my child while injured. I further authorize and consent to medical, surgical, and hospital care, treatment and procedures to be performed for my child’s health in the event I cannot be contacted. I waive my right of informed consent to such treatment. I also give my permission for my child to be transported by ambulance or aid car to an emergency center for treatment should an accident or illness require immediate medical attention.

Physician’s Name___________________________________________________Phone_______________________________

Physician’s Address______________________________________________________________________________________

Clinic or Hospital Preferred:__________________________________________________Date of Last Tetanus_____________

Illnesses:_____________________________________________Blood type______________________

Medications:________________________________________________

List any allergies and any intolerances to food/medication or substance:

________________________________________________________________________

Action Plan: to take in any emergency situation regarding allergies or intolerances:

________________________________________________________________________

Does the child have any chronic illness, physical problems, health concerns or development issues?

If yes, please describe any accommodation needed.

________________________________________________________________________

Insurance Carrier______________________________________Subscriber’s Name___________________________________

Address_____________________________________________Subscriber’s ID Number_______________________________

City_______________________________State_____Zip______Group ID Number____________________________________

Office Use Only: Child’s Proof of Identity

Document used for verification_____________________________________________________________________________

Document Number:________________________________________________Date Issued:____________________________

Place of Birth_____________________________________________________Date of Birth:___________________________

Verification Signature_______________________________________________Date__________________________________

Discovery Learning Center Personal Record: to increase our understanding of your child’s personality and life

experience, please take a few moments to share the following information with us.

Has your child had any previous experience in a group care setting? NO______ YES______ if yes please describe

______________________________________________________________________________________________________

Please describe your child in the following:

Relating/interacting with other adults:_________________________________________________________________________

Relating/interacting with other children:_______________________________________________________________________

Separation from parents:__________________________________________________________________________________

Eating/Sleeping/Dressing:_________________________________________________________________________________

Times that your child finds stressful or difficult:_________________________________________________________________

Personality:_____________________________________________________________________________________________

Please call the center by 8am if your child will not be attending on his regularly scheduled day.

I hereby grant permission for my child to participate in any and all of the child care activities and to use any of the

equipment to include all indoor and outdoor toys, swings, slides, blocks, scissors, climbing structures etc. Discovery

Learning Center is not responsible for any accidents that occur while my child is playing on such equipment.

Initial ___________

You will be notified of every fieldtrip your child will participate in away from the center. Please leave a carseat.

Authorization to treat Minor Injuries or Accidents

I hereby authorize Discovery Learning Center faculty to administer medical treatment and or first-aid for any minor

injury or accident while my child is in their care and hold Discovery Learning Center harmless.

Initial ___________

I understand that my child cannot attend Discovery Learning Center when ill. I authorize the center to contact me in

the event my child becomes ill while in attendance. I agree to pick-up my child or make arrangements for an authorized

individual to pick up my child within 1 hour of receiving notification. The state requires a child needs to go home

within the hour if he has a fever of 100 degrees or greater or has 2 runny stools in an hour that cannot be contained

within the diaper. Please refer to Parent handbook for state guidelines regarding illnesses.

I understand that I must notify Discovery Learning Center in the event that a communicable disease occurs within my immediate family.

For example Ringworm, Streptococcus, Scabies, Chicken Pox and Lice could be hazardous to our child care population. I understand my child cannot attend the center until all symptoms are gone and a Doctor’s note clearly states my child is

no longer contagious and can return to Discovery Learning Center. Please refer to Parent Handbook for regulations.

In the event that you privately contract for child care services, transportation, or assistance with any Discovery Learning

Center employee, Discovery Learning Center will neither be held responsible nor liable for any accidents, injuries, or

other incidents arising there from. I agree to hold harmless Discovery Learning Center from any and all legal action

arising for any independent child care or other arrangement with Discovery Learning Center employees.

In the event that Discovery Learning Center has reason to suspect the occurrence of physical, sexual or emotional abuse,

neglect, or exploitation of a child. Discovery Learning Center will, as required by South Dakota Department of Child

Care Services report the incident immediately to The Department of Child Care Services Division of Child Protection

Services.

I give permission for emergency care decisions to be made by the Discovery Learning Center staff regarding my child in

the event of an emergency that impedes regular center operations and will hold Discovery Learning Center harmless.

Initial here______________

After a child has been continually enrolled for a period of 4 weeks, the child is entitled to 10 free days if full-time or 5 days

if part-time with no tuition due to maintain their enrollment. Parents must notify director two weeks in advance of their intention to use free days. Please refer to the Parent handbook for rules and regulations regarding free days.

Free day slips are provided on the parent information board or in the office. Free day slips are turned in with tuition.

*Regular tuition rates will apply to all days absent beyond allowed free days.

I have read, understand and agree to the above authorizations.

Parents/Guardian Signature____________________________________________________Date_______________________

Discovery Learning Center is open 6:30am—6:30pm, Monday through Friday year round. We are closed for the following paid holidays :Labor Day, Thanksgiving Day, Christmas Day, New Year’s Day, Memorial Day and Independence Day,

President's day and Easter Monday.

In consideration of our faculty, Discovery Learning Center will close each year at 3:00pm on Christmas Eve &

New Year's Eve.

In the unlikely event that Discovery Learning Center will close for inclement weather, we will announce closing on

KELO 92.5 radio. Please listen to local radio and television for closings. We will contact you if the severity of the weather

dictates an early closing.

Tuition is charged for the week your child is attending. Tuition is based on your enrollment at Discovery Learning Center

not based on your child’s attendance. Regular tuition will apply to all days absent beyond allowed free days.

PLEASE INITIAL______.

Tuition is due each week on Monday. If tuition is not received before the close of business

on Monday, a late fee of $20.00 will be assessed. Children may be denied access to the center if payments are

overdue.

Payments should be made by cash, local check, money order or cashier's check.

Discovery Learning Center charges $30.00 for each returned check. Parents are expected to replace returned checks with

2 days of notification by their bank or Discovery Learning Center. Discovery Learning Center will require payment be

guaranteed funds in the event 2 checks are returned within a calendar year.

I hereby request that my child(ren),__________________________________________________ be permitted to participate

in field trips outside of the center for his/her benefit in attendance at Discovery Learning Center. Initials _____________

I give Discovery Learning Center permission to administer the following medication,______________________________

to my child(ren),__________________________________________.

Parent Signature________________________________________________.

Discovery Learning Center charges an initial non-refundable fee of $25.00 per family. This non-refundable fee is

applicable to parents wishing to hold a spot in our facility until an opening is available and/or expectant parents.

Multi-Child Discount

Discovery Learning Center offers a 20% tuition discount for additional siblings, taken off the lowest tuition rate.

Late Pick Up

Discovery Learning Center closes each day at 6:30pm. Late pick-up fees of $1.00 per minute will be incurred whenever

pick-up is made after closing. Incurred late fees are immediately due. If no one listed on the child’s enrollment forms

responds to our telephone calls, the local police and or Department of Social Services will be notified exactly one hour

after closing.

Disenrollment

Discovery Learning Center reserves the right to disenroll for non-payment, failure to follow policies, and in the event of

behavior issues.

Withdrawal From Discovery Learning Center

Parents are required to give two weeks written notice of their intention to withdraw their child from the center.

Without such written notice, parents are liable to pay the center for two weeks tuition, late fees, collection fees

and reasonable attorney fees.

Initial here:_______________

I have read, understand and agree to all of the agreements and authorizations listed above, and I

am fully able to grant these authorizations/agreements, as the parent or legal guardian, of the child

listed previously in this forms. I do voluntarily make these authorizations and agreements as listed

above with Discovery Learning Center. I understand Discovery has the right to make changes including

but, not limited to: fees, paid holidays, closed holidays, tuition, and hours of operation, policies and

procedures.

___________________________________________________________________________________________________

Parent/Guardian Signature Date Tuition Rate

___________________________________________________________________________________________________

Director's Signature Start Date Tuition Rate

Place your photo here.

For your convenience parents can print enrollment forms. Please call Discovery for availability and an appointment for enrollment. Please bring:

A current copy of your child's immunization record

Registration fee of $50

Upon enrollment a Parent Handbook will be given to you and an "About My Child" form to give us more detailed information about your child's personality and needs. You will also be given a menu, class schedule, list of classroom supplies, security entry code, and your child's classroom activity calendar & attendance calendar for the current month.

CHILD'S INFORMATION:

EMERGENCY CONTACTS

ENROLLMENT AUTHORIZATIONS/PARTICIPATION PERMISSION

PHYSICIAN INFORMATION

EMERGENCY MEDICAL AUTHORIZATION

MEDICAL INSURANCE INFORMATION

ILLNESS NOTIFICATION & PICK-UP

COMMUNICABLE DISEASE

PRIVATE CARE EXCLUSION

SOUTH DAKOTA DEPARTMENT OF CHILD PROTECTIVE SERVICES

EMERGENCY CARE AUTHORIZATION

FREE DAYS/VACATION DAYS

ENROLLMENT AGREEMENT

TUITION

RETURNED CHECKS

REGISTRATION FEE

Welcome! Thank you for Discovering the difference!

*This is a sample of our policies. Please refer to our Parent Handbook for detailed Rules and Regulations with State guidelines for our center from the South Dakota Department of Child Care Services.

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(605) 274-3475 We will see you soon!

Discovery Learning Center in Sioux Falls, SD (605) 274-3475

Website created by Lissa Hoxsie

FIELDTRIP PERMISSION

MEDICATION ADMINISTRATION