Open 24 hours | Mon – Fri Saturdays open till 10 pm | Closed Sundays

Enrollment Agreement Form

Completion of this agreement is required for enrollment. This form will enable us to better understand your child and meet his/her needs. Much of the information requested is necessary to comply with state child care licensing regulations.

Date of Admission:
Enrollment Information
Child’s Information
Child’s first name
Child’s middle name
Child’s last name
Child’s nickname
DOB
SexMaleFemale
Child’s primary language
Parent/guardian/sponsor primary language
Child’s home address
City
State
Zip
Does your child attend school?YesNo
School name
Grade
School phone
School address
Drop off time
Pick-up time
Family Information
List family members & pets your child lives with – include first names, relation and ages of siblings.
Parent/guardian/sponsor
Relationship to child
Home phone
Cell phone
Home address if different from above
City
State
Zip
Home email
Work email
Work phone
Employer
Employer address
City
State
Zip
Other parent/guardian/sponsor
Relationship to child
Home phone
Cell phone
Home address if different from above
City
State
Zip
Home email
Work email
Work phone
Employer
Employer address
City
State
Zip
Child Emergency Contact and Release Information (do not include parents/guardians/sponsors)
Please notify Christian Child Cares if an Emergency Release Contact will pick up your child on a given day. [For the safety of your child, we request that all authorized pick up persons with whom staff is not familiar provide a photo ID at the time of pick up.]
Person #1
Relationship to child
Home phone
Cell phone
Home address if different from above
City
State
Zip
Home email
Work email
Work phone
Employer
Employer address
City
State
Zip
Person #2
Relationship to child
Home phone
Cell phone
Home address if different from above
City
State
Zip
Home email
Work email
Work phone
Employer
Employer address
City
State
Zip
Person #3
Relationship to child
Home phone
Cell phone
Home address if different from above
City
State
Zip
Home email
Work email
Work phone
Employer
Employer address
City
State
Zip

The persons designated in this section will be contacted by us if you cannot be reached in the event of a medical or other emergency. Our staff will only release your child to you or to those persons listed above. If you want a person who is not identified above to pick up your child, you must notify our staff in advance, in writing. Your child will not be released without prior authorization.

Parent initial
Staff initial
Date
Permission to Apply Sunscreen
I give my permission to Christian Child Cares to apply
sunscreen
and
insect repellent
Initial
to my child. Please check which product you will permit.
I understand that I must supply my own sunscreen and/or insect repellent with a valid expiration date, and it will be labeled with my child’s name.
Initial
I have special instructions for the application process .
NoneStick lotion for the face.
Regular sunscreen for the rest of the body.
Parent initial
Staff initial
Date
Individualized Education Plans (IEP) & Individualized Family Service Plans (IFSP)

The information found on an IEP/IFSP is protected by privacy laws including the Health Insurance Portability and Accountability Act (HIPAA). Releases of information may also be required to speak to members of a child’s treatment team. Professional development regarding privacy issues, and HIPAA in particular, is highly recommended.

Child’s Name:
Your child’s growth and development is measured with developmental assessments. If your child currently has an IEP/IFSP, it would be beneficial to share a copy of this plan with us so we can work together to ensure that the guidelines are put into practice. You do not have to provide this information if you do not wish to do so.

I am providing a copy of my child’s IEP or IFSP.

I am not providing a copy of my child’s IEP or IFSP and/or this is not applicable to my child.

Signature:
Date:
Rate Agreement and Contract
Hours of Operation
Regular operating hours are Monday through Friday 24 hours and Saturday from 12:00 AM to 10:00 PM except closings for various holidays, and inclement weather as described in the Family Handbook. Please consult the current calendar for holidays. There is no reduction in tuition as a result of closures.
The procedure to notify families should severe weather or other conditions prevent the program from opening on time or at all will be announced on radio station WNEP If it becomes necessary to close early, we will contact you or someone listed in the Emergency Contact and Release, and it will be your responsibility to arrange for your child’s early pick up.
Services Provided

Services to be provided as part of the child care fee are: meals, educational program for infants, toddlers and preschool children, afterschool program & homework assistance. Pickup from school for school-agers if within walking distance. Walking excursions to local parks & library.

Services to be provided at an additional fees are: tutoring, field trips that require admission fees & transportation
Scheduled Attendance
The days and hours that I wish to contract for child care are as follows:
Day of week
Start time
AM/PM
End time
AM/PM
Comments
Monday




Tuesday




Wednesday




Thursday




Friday




Saturday




I would prefer to make tuition payments on a
basis
Child's Name Parent/Guardian
Birth Date

Relationship

Fee Policy (to be completed by staff; reviewed and initialed by the parent/guardian/sponsor after completion)
- Starting on
a fee of $
is due
Initial
- Tuition is due and payable on the

- Tuition is not subject to discounts for holidays, emergency closures (i.e., weather), illness or absences other than hospitalization (a written doctor’s note is required to receive credit).

- Enrollment: One week’s tuition is required upon enrollment to hold a spot for your child. This enrollment fee is nonrefundable, but will be applied to your child’s last week of tuition.

- I agree to pay the full tuition in advance of services rendered.

- I agree to pay the full tuition fee even if my child is absent for one or more days.

- A late payment fee of $5 per day is due if tuition is not received on time up to 7 days after which your child cannot come unless fees paid.

- A non-refundable registration fee of $39.50 is due yearly at the beginning of each academic year for regular child Care and at the second visit for drop-in care.
- A non-refundable registration fee of $12.00 for providing personal child care.


- Late Pick up Fee: A $0.75 per minute charge up to $20 will be applicable when a child is picked up after the scheduled hours. Late Fees will be charged to your account. You will be given an invoice and expected to pay it the day after it was incurred. Failure to pay this will result in additional late fees being charged to your account at the normal charge for late fees as outlined in the Parent Handbook..
- Fees for Unscheduled Child Care - Child care fees for any unscheduled hours are $160.00 per week for regular hours, or if less than 1 week, $35.00 per full day, or if less than 1 day, $9.00 per hour.


- If your account has not been paid in full within 7 days, your child will not be allowed to attend the facility until payment is received in full. Accounts two weeks in arrears may result in immediate termination of service.

- My child may have the opportunity to participate in a special program or field trip that may have an additional fee due before the day of the event. A specific permission slip may be required.

- All returned checks or ACH transactions (automatic debits) will be charged a fee $30 up to the maximum amount allowed by law. Two or more returned checks or ACH transactions will result in my account being place on “money order only” status.

- A receipt for income tax purposes will be provided by the end of the first year for parents that are current
with their payments.

Parent initial
Staff initial
Date
Other Agreements
Private Employment Acknowledgement and Release

Any arrangement/employment between me and staff of Christian Child Cares (i.e., babysitting), outside of the programs and services offered by Christian Child Cares, is an individual endeavor and private matter not connected or sanctioned by Christian Child Cares. Christian Child Cares shall remain harmless from any such arrangement.
Initial
Parent initial
Staff initial
Date
Handbook Acknowledgement

I understand and agree that it is my responsibility to read and familiarize myself with policies and procedures outlined in the Family Handbook and agree to abide by them.
Initial

I understand that it is my responsibility to go directly to management with any questions I may have regarding the policies and procedures and information contained in this Enrollment Agreement.

Information contained in the Family Handbook may be subject to change.
Contract Approval

I certify that I have read, understand, and accept all of the terms and conditions described in this Enrollment Agreement and the Family Handbook.
Initial
Primary Parent/Guardian/Sponsor Signature
Date:
Staff Signature
Date:
  • A regular week is defined as hours between 6 a.m. through 6.59 p.m. Monday through Friday. Any other times are referred to as nontraditional hours. Refer to the rate sheet for clarification for rates for nontraditional hours etc.
  • We’ve only listed a few pertinent policies that may affect you. Please consult the family handbook for more detailed information on Christian Child Cares Policies.