1

Enrollment 2012

Misty M. Slater

10956 SW Bretton Ct

Tigard, OR 97224

Phone: 503.679.8539

Email: misty@littlefeetchildcare.com

http://www.littlefeetchildcare.com

ENROLLMENT APPLICATION

2012 Child’s Name:

Date of Birth:

Address:

Phone:

GUARDIAN INFORMATION Guardian 1’s Name: Home Phone:

Address: Work Phone:

Cell Phone:

Employer:

Address:

Date of Birth:

Email:

Guardian 2’s Name: Home Phone:

Address: Work Phone:

Cell Phone:

Employer:

Address:

Date of Birth:

Email:

MEDICAL FORM

(FILE COPY)

Enrollment Status: Enrollment Date: Student ID: __________________

If there is a court order for guardianship, LFCC must have a copy of the court order on file at time of enrollment

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Enrollment 2012

Child’s Name: DOB:

Mother’s Name: Phone:

Father’s Name: Phone:

Insured Name:

Insurance Carrier: Policy #:

Doctor’s Name: Phone:

Address:

Dentist Name: Phone:

Our child care provider, MISTY SLATER has our permission for the following:

(please check all that apply)

o to call an ambulance if necessary

o to take our child to a physician or hospital in case of emergency

o to give prescription medication when instructed as prescribed by child’s physician

o to give non-prescription medication as instructed by parents

o Tylenol

o Motrin

o Orajel

o Teething tablets

o Sunscreen (LFCC supplies Neutrogena Sunscreen)

o Other Sunscreen (you must supply it)

o Other (please specify)

I/We understand that any medical expenses necessary are my/our responsibility.

_________________________ ______________________

Signature Signature

_________________________ ______________________

Date Date

Immunization Record on File Y N

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Enrollment 2012

MEDICAL FORM

(EMERGENCY COPY)

Child’s Name: DOB:

Guardian 1’s Name: Phone:

Guardian 2’s Name: Phone:

Insured Name: Policy #:

Insurance Carrier:

Doctor’s Name: Phone:

Address:

Dentist Name: Phone:

Our child care provider, MISTY SLATER has our permission for the following:

(please check all that apply)

o to call an ambulance if necessary

o to take our child to a physician or hospital in case of emergency

o to give prescription medication when instructed as prescribed by child’s physician

o to give non-prescription medication as instructed by parents

o Tylenol

o Motrin

o Orajel

o Teething tablets

o Sunscreen (LFCC supplies Neutrogena)

o Other Sunscreen (you must supply)

o Other (please specify)

I/We understand that any medical expenses necessary are my/our responsibility.

_________________________ ______________________

Signature Signature

_________________________ ______________________

Date Date

Immunization Record on File Y N

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Enrollment 2012

EMERGENCY RELEASE FORM

(EMERGENCY COPY) Either a parent or a guardian, having legal custody of a minor, may give written authorization for an adult, into whose care the

minor has been entrusted, to consent to x-ray examinations, anesthesia, medical or surgical diagnosis and/or treatment and

hospital care to be rendered, to the said minor, under the provisions of the medical practice act, or to x-ray examinations,

anesthesia, dental and/or treatment and hospital care to be rendered to said minor by a dentist licensed under the dental

provisions law.

Child’s Name:

Child’s Doctor: Phone:

Child’s Dentist: Phone:

Insured Company: Policy #:

Guardian 1’s Name: Guardian 2’s Name:

Home Phone: Home Phone:

Work Phone: Work Phone:

Cell Phone: Cell Phone:

AUTHORIZATION I ___________ and/or ____________ understand the above and hereby authorize Misty M. Slater , owner of

Little Feet Child Care, LLC to give permission for any necessary medical, hospital or dental treatment for my child,

________ in the event of injury or illness while the child is in care of the above name provider or center. I understand

and agree that I would be financially responsible for any medical treatment necessary. I have full understanding that every

attempt will be made to contact the parent/guardian in the even that medical treatment is necessary. I understand that certain

medical emergencies may not allow much time for contact of the parent/guardian and that if a life threatening situation arises,

immediate attention will be sought by the provider.

______________________________ _________________________

Signature Signature

_______________________________ _________________________

Date Date

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Enrollment 2012

EMERGENCY RELEASE FORM

(FILE COPY) Either a parent or a guardian, having legal custody of a minor, may give written authorization for an adult, into whose care the

minor has been entrusted, to consent to x-ray examinations, anesthesia, medical or surgical diagnosis and/or treatment and

hospital care to be rendered, to the said minor, under the provisions of the medical practice act, or to x-ray examinations,

anesthesia, dental and/or treatment and hospital care to be rendered to said minor by a dentist licensed under the dental

provisions law.

Child’s Name:

Child’s Doctor: Phone:

Child’s Dentist: Phone:

Insured Company: Policy #:

Guardian 1’s Name: Guardian 2’s Name:

Home Phone: Home Phone:

Work Phone: Work Phone:

Cell Phone: Cell Phone:

AUTHORIZATION I ___________ and/or ____________ understand the above and hereby authorize Misty M. Slater , owner of

Little Feet Child Care, LLC to give permission for any necessary medical, hospital or dental treatment for my child,

________ in the event of injury or illness while the child is in care of the above name provider or center. I understand

and agree that I would be financially responsible for any medical treatment necessary. I have full understanding that every

attempt will be made to contact the parent/guardian in the even that medical treatment is necessary. I understand that certain

medical emergencies may not allow much time for contact of the parent/guardian and that if a life threatening situation arises,

immediate attention will be sought by the provider.

______________________________ _________________________

Signature Signature

______________________________ _________________________

Date Date

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Enrollment 2012

HEALTH HISTORY

Child’s Name: Date of Birth:

Last Physical Exam:

**A COPY OF YOUR CHILD'S IMMUNIZATION RECORD FROM THE DOCTOR IS REQUIRED

FOR YOUR CHILD'S FILE**

Vaccination Dose 1 Dose 2 Dose 3 Dose 4 Dose 5

Diptheria/Tetanus

DTaP

2 months 4 months 6 months 18 months 5 years

Polio

IPV or OPPV

6 months 9 months 18 months 5 years

Chickenpox

Varicella

12 months Booster

Measles/Mumps/Rubella

MMR

12 months 5 years

Hepatitis B

Hep B

1 month 2 months 9 months

Haemophilus Influenza

Hib

2 months 4 months 6 months 15 months

Hepatitis A

Hep A

Pneumococcal

PCV7 (under 5)

2 months 4 months 6 months 18 months

Meningococcal

MCV7 (ages 11-18)

Tetanus/Diptheria

Booster

12-15 years

Other:

Other:

Other:

Other:

Allergies:

Dietary Restrictions

Has your child been hospitalized? (explain)

_____________________________________________________________

_____________________________________________________________

Has your child had injuries with fractures or loss of consciousness? (explain)

_____________________________________________________________

_____________________________________________________________

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Enrollment 2012

PICK UP AUTHORIZATIONS

The following people listed below are allowed to pick up my/our child,

, if instructed by the parent/guardian.

Name: Phone:

Name: Phone:

Name: Phone:

Name: Phone:

Name: Phone:

Name: Phone:

Additional Comments:

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

IN CASE OF AN EMERGENCY In case of an emergency, please contact one of the following if the parent/guardian cannot be reached.

Name: Phone:

Name: Phone:

Name: Phone:

Name: Phone:

Name: Phone:

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Enrollment 2012

PHOTOGRAPH RELEASE

I/We _______________________, give permission for Misty M. Slater or staff at Little Feet Child Care, LLC to

photograph my child, ____________________. For the following purposes: (CHECK THOSE THAT APPLY)

o Still Photographs

o Display in Provider’s Scrapbook

o Give Photo’s to current clients

o Display on bulletin boards, shown to prospective Client’s

o Use still photos in promotional materials

o Upload to dropshots & snapfish for parents to print

o Little Feet Child Care, LLC Website (children's names are not used on website)

o Little Feet Child Care, LLC Facebook Page (children's names are not used on Facebook)

WATER RELEASE

I/WE give permission__ I/WE do not give permission __ to Misty Slater and staff of Little Feet Child Care, LLC for

my/our child to participate in water play (touch tub) or swimming activities (sprinklers) NO POOLS!

________________ _____________________

Signature Signature

________________ _____________________

Date Date

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Enrollment 2012

TUITION CONTRACT

Child’s Name: Date of Birth:

I __________and/or ___________ are in agreement that, I/WE will pay $ per month for

child care days per week to Little Feet Child Care, LLC. Payment is due at the beginning of the month. Payment

is required in advance. I/We understand that if our payment is received by provider, past the agreed upon payment date, we will be charged as

follows: a late payment of $25.00 for each day the payment is late. In addition, I/WE understand and agree that an additional

fee of $2.00 per minute will be charged if child(ren) are not picked up as agreed on this contract.

DAYS OF THE WEEK HOURS OF THE DAY

o Monday 7:00-5:30

o Tuesday 7:00-5:30

o Wednesday 7:00-5:30

o Thursday 7:00-5:30

o Friday 7:00-5:30

Additional Terms: Late fees will not apply if there are poor road conditions such as snow, ice, freezing rain, etc. If these are

the conditions, please call to inform provider that you will be arriving late.

If provider should receive a check back, due to insufficient funds, there will be a fee of $35.00. Late payment and/or

insufficient funds may result in termination of your child’s enrollment.

Should I/WE decide to discontinue child care services, I/WE will give 30 days notice. If 30 day notice is not given in writing,

tuition will not be reimbursed for those days.

________________ ______________

Signature Signature

________________ _____________

Date Date

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Enrollment 2012

CHILD CARE CLOSURES CONTRACT

I/We understand that the following days are paid closure days for Little Feet Child Care, LLC and are

responsible for finding our own back child care if necessary.

2012 HOLIDAY AND VACATION CLOSURES

All Vacation Days And Holidays Are Paid

January 2012 No Closures February 2012 Monday, February 20th President’s Day March 2012 Mon-Fri, March 26th -30th Vacation April 2012 No Closures May 2012 Monday, May 28th Memorial Day June 2012 No Closures July 2012 Wednesday, July 4th Independence Day Mon-Fri, July 9th - 13th Vacation August 2012 Monday, August, 27th Vacation Friday, August 31st Vacation September 2012 Monday, September 3rd Labor Day Friday, September 21st Vacation October 2012 No Closures November 2012 T, F November 22nd - 23rd Thanksgiving December 2012 Mon-Fri, December 24th - 28th Vacation Monday, December 31st New Year's Eve January 2013 Tuesday, January 1st New Year's Day

_______________ _____________

Signature Signature

_______________ _____________

Date Date

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Enrollment 2012

ADDENDUM 2

ANNUAL ENROLLMENT FEE

The $100.00 annual enrollment fee is due prior to your child’s first day and January 1st every year after. The

fee helps to cover state required registration, training and licensing. However, if you enroll in the fall, you

will not accrue another enrollment fee in January. Your next enrollment fee will not come due until the

following January. For multiple children, the fee is $100.00 for the 1st child and $50.00 for each additional

child.

Example: Child A is enrolled in September 2011 and a $100.00 fee is charged. January 2012 arrives and the

$100.00 enrollment is waived. The next enrollment fee is due January 2013.

Signature Signature

Date Date

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Enrollment 2012

ADDENDUM 3

DISCIPLINARY GUIDELINES

Little Feet Child Care, LLC follows the following guidelines for and not limited to…

Biting

Hitting

Kicking

Inappropriate Language

Any behavior which endangers the child(ren), teacher or environment

1. IDENTIFY-the inappropriate behavior

2. DOCUMENT-behavior, time of incident, place, activity occurring, including staff and director signatures

3. INFORM-parent (verbally and written, requiring parent signature)

4. OBSERVE-the environment, schedule, child/child interaction, developmental stages, staff/child interaction

5. CONFERENCE-with parent(s), teacher and director

6. PLAN OF ACTION-developed with developmentally appropriate practices as a guideline, in conjunction with

parent(s) and facility input. Including responsibilities of each party, time frame and date of follow up with the

understanding that any inappropriate behavior can and will necessitate immediate response which could occur prior

to scheduled follow up conference

7. FOLLOW UP AND OBSERVATION-track either successful improvement or any continuation of the inappropriate

behavior

8. COMMUNICATE-with parent(s) concerning observation. Could require development of an additional action plan

and/or request for alternative care

If the inappropriate behavior persists and/or the behavior is demonstrated routinely, Little Feet Child Care, LLC reserves the

right to request that alternative care be provided which can include one or all of the following: removal from daycare on the

day of the incident, brief request of absence from daycare, or dis-enrollment.

_______________ _____________

Signature Signature

_______________ _____________

Date Date

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Enrollment 2012

ADDENDUM 1

(YOUR COPY)

2012 HOLIDAY AND VACATION CLOSURES

All Vacation Days And Holidays Are Paid

January 2012 No Closures

February 2012 Monday, February 20th President’s Day

March 2012 Mon-Fri, March 26th -30th Vacation

April 2012 No Closures

May 2012 Monday, May 28th Memorial Day

June 2012 No Closures

July 2012 Wednesday, July 4th Independence Day

Mon-Fri, July 9th - 13th Vacation

August 2012 Monday, August, 27th Vacation

Friday, August 31st Vacation

September 2012 Monday, September 3rd Labor Day

Friday, September 21st Vacation

October 2012 No Closures

November 2012 T, F November 22nd - 23rd Thanksgiving

December 2012 Mon-Fri, December 24th - 28th Vacation

Monday, December 31st New Year's Eve

January 2013 Tuesday, January 1st New Year's Day