ENROLLMENT AGREEMENT​

ENROLLMENT INFORMATION​
please complete this Enrollment Agreement accurately and completely, as this information is necessary for Little Scholars Academy Academy to comply with state child care licensing regulations, as well as to understand your child and meet his or her individual needs. Completion of the Enrollment Agreement is required for enrollment at Little Scholars Academy Academy.

CHILD INFORMATION

Circle the day(s) of the week care is needed Write time(s) beneath the day it pertains to

PARENT/GUARDIAN INFORMATION

EMERGENCY CONTACT AND RELEASE PERSONS – OTHER THAN PARENTS/GUARDIANS

Please list below the names and contact information of those persons other than yourself you hereby authorize to pick up your child from the school. Emergency contacts must not include people residing in your household but must be friends or other family members who do not live with you and are familiar with your child. Little Scholars Academy Academy will only release your child to adults you designate as authorized. It is our policy to ask all unfamiliar adults for photo identification. If possible, please notify the school if someone other than the primary or secondary parent/guardian will be picking up your child on a given day. A minimum of two emergency contacts are required.
***YOU AGREE TO THESE TERMS FOR THE DURATION OF CARE***

ENROLLMENT AGREEMENT

HEALTH AND DEVELOPMENTAL HISTORY
GENERAL HISTORY
DAILY ROUTINES – INFANTS
5: What is your child’s present eating schedule? List type and amount of food:
DAILY ROUTINES – TODDLERS/PRESCHOOLERS
TOILETING
________________________________________________________________________________________________________________
MEDICAL INFORMATION
ALLERGIES
1. My child does have food or environmental allergies, asthma, or special food accommodations as determined by a physician or religious preferences. If yes, please continue on to question 2. If no, please go on to the next section.
2. My child has allergies (please check all that apply). If checked, please fill out Individual Allergy Action Plan, along with appropriate prescription and nonprescription medication release forms (Long-Term Prescription Medication Release and Authorization for Over-the-Counter Allergy Medication)
3. My child has asthma. If yes, please fill out Individual Asthma Action Plan, along with appropriate prescription and non-prescription medication release forms (Long-Term Medication Release, etc.).
4. My child has special diet accommodations (including allergies, food intolerance, and/or cultural/religious preferences). If yes, please complete Special Foods Needs and/or Special Diet Statement.
MEDICAL PROVIDERS AND HEALTH INSURANCE INFORMATION
EMERGENCY CARD
PARENT/GUARDIAN
PHONE NUMBERS
THE FOLLOWING INFORMATION IS REQUIRED BY THE DEPARTMENT OF HUMAN SERVICES
EMERGENCY CONTACT/AUTHORIZED PICKUP
*(MUST BE DIFFERENT FROM PARENT/GUARDIAN)

1

2

I give permission to Little Scholars Academy to make whatever emergency (e.g., first aid, disaster evacuation) measures are judged necessary for the care and protection of my child while under the supervision of the school.
In case of a medical/dental emergency, I understand that my child will be transported to an appropriate medical facility by the local emergency unit for treatment if the local emergency resource (police, rescue squad) deems it necessary.
It is understood that in some medical situations, the staff will need to contact the local emergency resource before the parent, child’s physician, and/or other adult acting on the parent’s behalf.
By signing this form, I authorize Little Scholars Academy to release any information pertaining to my child to persons listed as an emergency contact or authorized pickup.