Pantherhugs

~Enrollment Forms~

Child’s Name:____________________________DOB:_____________________

Address: _________________________________Home Phone:_____________

Mother’s Name___________________________

SS#__________________________

Work Address:________________________ Work Phone:________________

Father’s Name: ________________________

SS#___________________________

Work Address: _______________________ Work Phone:_________________

Basic Rates and Payments

Hours of operation: Monday - Friday 7:00 am - 5:30 pm

DROP OFF TIME___________ PICK UP TIME___________

Days of care: MON______ TUES______ WED______ THURS______ FRI______

*Fee for care:_________week, due and payable no later than the 1st day of care for each week.
This fee is payable whether the child does or does not attend care on the days as agreed upon above.

*Fee is to be paid by check or cash. There will be a $25.00 fee for returned or NSF checks.

NOTICE: I close at 5:30 p.m. A fee of $1.00 per minute will be added to your fee.
After three late pick-ups, you will be given a two week notice to find alternate care for your child.

Holidays:

All major holidays will be paid if it lands on a day of the week your child is enrolled.
No childcare services will be provided on the following days:

New Years Day, Memorial Day, Fourth of July

Labor Day, Thanksgiving, Christmas

Vacations & Absences

*I will take two one-week vacations: these weeks will be paid.

*When you take vacation you are required to pay your regular tuition.

*I require payment regardless if your child is out sick or just taking a day off.
I do not require payment if I or my children are ill and I have to be closed.

*If I do have to close in case of an emergency or my own children becoming ill,
it is the parents responsibility to find alternate care for their child.

Termination

For the termination of care, both parties agree to submit to the other: two weeks written notice.
These two weeks will be paid regardless if your child is in attendance or not.

The undersigned have read, understood and agree to the terms and conditions of this agreement as outlined.

Parent Signature_________________ Date_________________________

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Registration Form

Child’s Full Name: ________________ Birth Date: ___________________

Address: _________________________ Home Phone: _________________

City: _____________________ State:____________ Zip Code:________________

Date Enrolled: ___________________ Nickname: _____________________

Mother’s Full Name: ______________SS#: ____________________

Address: _________________________Home Phone: ___________

City: ___________________State: ______________ Zip Code: ________

Occupation: ___________________ Work Phone: _______________________

Name of Employer: _____________Cell Phone: ______________

Business Address: _______________Work Hours: _______________________

Father’s Full Name: _________________SS#: _____________________

Address: _______________________ Home Phone: _______________________

City: ___________________ State: _____________ Zip Code: ________

Occupation: ______________________ Work Phone: ______________________

Name of Employer: ________________Cell Phone: ______________________

Business Address: ________________ Work Hours: _____________________

Parent/Guardian with legal custody: __________________

Parents are: Married_____ Divorced_____ Separated_____ Widowed_____ Single_____

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About Your Child

CHILD’S NAME_______________

What FOODS does your child especially like? _________________

Especially DISLIKE? _________________________

Favorite toys, games, activities? _________________________

Is your child POTTY TRAINED? _________________________

How does your child express ANGER or FRUSTRATION? ________
_______________________________________________________________

Does your child have any special FEARS? _________
_______________________________________________________________

When your child is upset, what helps to comfort him/her? __________
_____________________________________________________________________

Has your child been taking afternoon naps? ______________ If so, how long? ________

If not, why? _________________________________

Special toy or blanket for NAP? __________________

Special FAMILY situations, i.e. custody specifications,
problems arising from situations, etc.? ______________

Anticipated ADJUSTMENT problems? _______________________________

Any disorders/developmental (slow, advanced) diagnosed or suspected? _____________
____________________________________________

Previous daycare child has attended? ________________________

Any problems at previous daycare? __________________________

Your EXPECTATIONS of Panther Hugs Daycare: ___________________________
__________________________________________________________________________.

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Notice of Animal on Premises

Child’s Name: ______________________________________________________________

This is to confirm that the parent/guardian of the
above listed child has been notified that the following
animal is on the premises of the childcare facility and
will be present around the child in care.

Jake (Golden Retriever)

Parent’s Signature: ____________Date: ____________

Media Authorization

Child’s Name: _____________

I authorize Annette Spence of Panther Hugs Daycare to photograph my child.

I understand that such photographs may be used for promotional
materials including, but not limited to, brochures, newsletters
and Panther Hugs website. No last name or specific identifying
information will be included in any sort of material.
IF I do not want any photo on the website for any reason,
___I understand Annette will gladly remove it as soon as possible.
___I do not authorize Annette Spence of Panther Hugs Daycare to photograph my child.

Parent’s Signature: __________ Date: ________

Transportation & Field Trip Permission

I hereby request that my child, ______________ be permitted to participate in
field trips to the park, or any other activities that would involve taking the
child outside of the daycare for his/her benefit in attendance at this facility.
In automobiles, children will be secured in car seats, as supplied by the parent(s),
with a safety belt as appropriate for their age.

I hereby expressly waive any claim for injury or damage to such
child arising out of such field trip and expressly agree to hold
Panther Hugs Daycare harmless.

Parent’s Signature: _____________ Date: ______

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Permission to use Sunscreen

I give Panther Hugs Daycare permission to use sun block on my child, ___________________,
while in care. I will supply Annette with the sun block of my choice to use for my child.

__________________________________ ______________

Parent/Guardian Signature Date

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External Preparations Permission

I hereby give Annette Spence/Provider permission
to apply one or more of the following external preparations,
in accordance with the directions for use on the container.

( ) Band-aids

( ) Neosporin or similar ointment

( ) Bactine or similar first-aid spray

( ) * Insect repellent

( ) * Non-prescription ointment (such as A & D, desitin, vaseline)

( ) * Other: (please specify) _______________________________

* Must be provided by the parent.

I release Annette Spence from any liability for administering these preparations.

__________________________________ ______________

Parent/Guardian Signature Date

Child Abuse/Neglect Protocol

As a licensed childcare provider, I am a mandated reporter,
required by law to report any suspected abuse or neglect of children.
If I fail to report, it could lead to personal penalties ranging from misdemeanor charges,
to civil liability for damages caused by the failure.
This is strictly for the benefit of your child.

If I assume that there is any kind of child abuse committed on any child in my care,
and if I perceive or think that anything questionable is present as far as abuse or
neglect is concerned, I will IMMEDIATELY contact the Police Department as we as
Child Protective Services.

By signing this form, you agree that it is in the best interest of your child.

__________________________________ ______________

Parent/Guardian Signature Date

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Emergency Contacts

(Within 20-mile radius of daycare other than parent or guardian)

Primary Emergency Contact (other than parent or guardian): ___________

Home Phone: _______________ Work Phone: ________

Relationship to Child: _________________

Address: _______________________________

Secondary Emergency Contact (other than parent or guardian): _________

Home Phone: ____________ Work Phone: __________________

Relationship to Child: ___________________________

Address: __________________________________________

Person(s) authorized to pick up my child (other than parents, guardians, or emergency contacts)

Name: __________________Phone Number: _____________

Name: ___________________Phone Number: ______________________

Person(s) NOT allowed to pick up my child:

Name: ______________________ Comments: _________________________

Name: _______________________Comments: _________________________

Name of school child attends: ___________ Phone Number: ______________

Parent Signature: ____________________ Date: ______________________

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Consent to Emergency First Aid & Transportation

I/We hereby give permission that my/our child, ________may be given emergency treatment
by Annette Spence/Provider of Panther Hugs Daycare.
I/We also give permission for my child to be transported by car,
ambulance, or Aid car to an emergency center for treatment,
and agree to hold Panther Hugs Daycare harmless.

Parent’s Signature __________________ Date: ________________________

Consent to Medical Care and Treatment

In the event I/We cannot be contacted immediately,
medical of surgical treatment can be administered
to my child in the case of an accident or emergency,
as prescribed by a treating physician, and agree to
hold Panther Hugs Daycare harmless.

Parent’s Signature ______________ Date: _________________________

I/We further acknowledge Panther Hugs Daycare shall not be responsible
for paying for the child’s health care. This includes negligent emergency
or damages that I/We or my/our child may suffer in any way related to the
use of the facility, toys, other children or employee, whether such claims are
known arise in the future.

Emergency Information

Child’s Physician_________________Phone Number ___________________

Preferred Hospital_______________ Phone Number____________________

Insurance Company______________Policy #_________________________

Medicaid_________________________Case #__________________________

Regular Medications______________________________________________

Blood Type_________________________Food Allergies_________________

Medicine Allergic to_______________________

Other Allergies___________________________

Special Health Conditions________________

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