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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.
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.
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.
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.
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.