Little MavericksLearning Center C h ild In fo rm a tio n a n d Med ic

Little Mavericks
Learning Center
Summer Program
Program Information
Little Mavericks’ Summer Program is open to all
children ages 1-12
Especially for Lil Mavericks
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Children:
Lil Mavericks: 1-3 (not potty trained)
Mavericks 3 -5
Big Mavericks elementary school aged
Dates:
Parachute Fun
Teddy Bear Picnics
Tea Parties
Lemonade Parties
Sensory Exploration
Water Play
Movement and Dance
Animal Parades
Toddler Olympics
Wagon Rides
Nature Walks
Especially for Mavericks
May 15-Aug 11 closed July 4th
Campus Field Trips:
 CMU Bio Building~ Green House
 CMU Library Children’s Center
 CMU Recreation Center
Weekly:
 Picnics
 Trips to the beach
 Fun Food Friday
 Water Day
 Movie Day
Daily Rates:
Lil Mavericks: …..… $30.00
Mavericks: ……..….. $25.00
Big Mavericks: ……. $20.00 daily
…………….……….. $25.00 special activity days
(See registration calendar for details)
Registration Fee:
$25.00 per child
Hours:
Monday-Friday………..6:45 am-5:30 pm
Food:
Lil Mavericks & Mavericks:
Morning and afternoon snack provided by LMLC
Sack Lunch provided by the parent
Big Mavericks (school aged)
Parents provide all snacks and lunch for their child
Especially for Big Mavericks
Weekly:
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Movie Day
Swimming
Hiking
Fishing
Sports Day
Arts and Crafts
Museums
Nature Center
Math and Science Center
MC Public Library
Police and Fire Stations
Bike Trips
Bike Rodeos
Playing at the Park
Banana Fun Park (End of Summer)
Little Mavericks Learning Center
Summer Enrollment Packet (1 year – 5 years)
Child Information and Medical Information
Child’s Name_____________________________________ Birth Date_____________________ Gender_____________
Address_______________________________________ City________________________________ Zip_____________
Name(s) and age(s) of siblings _________________________________________________________________________
Mother’s Name________________________________
Father’s Name_____________________________________
Birth Date____________________________________
Birth Date________________________________________
Social Sec #_________________________________
Social Sec #______________________________________
Address______________________________________
Address__________________________________________
Phone #______________________________________
Phone #__________________________________________
Employer_____________________________________
Employer________________________________________
Address______________________________________
Address_________________________________________
Phone #______________________________________
Phone #_________________________________________
CMU 700#____________________________________
CMU 700 #______________________________________
Custody issues or concerns
If there are custody issues involving your child, Little Mavericks must have copies of court papers.
Health History
Describe any surgeries, accidents, chronic illnesses or handicapping conditions.
Allergies: _____________________________________________________________________________________
Food Restrictions_______________________________________________________________________________
Physician’s Statement
(Statement of health Signed by Physician)
I find _______________________________to be in good health and able to attend Little Mavericks Learning Center
.
Are there restrictions to the child participating in any activities? If yes, please describe.
_____________________________________________
Physician’s Signature
_______________________________
Date
Please attach a copy of your child’s immunization records
Non Parent Emergency Contacts
Please list the persons you would like contacted (in order of priority) if you cannot be reached in case of emergency. For
the safety of your child, we will request all authorized release persons with whom staff are not familiar to provide
Government-issued photo identification at the time of pick-up.
Persons listed below are authorized to pick up the child in case of a campus wide or building evacuation. These persons
will also be called in if the parent cannot be reached during the school day if the child needs picked up for any reason.
Contacts must live locally
Emergency Contact Information
Name__________________________________ Phone #___________________Relationship______________________
Name__________________________________ Phone #___________________Relationship______________________
Name__________________________________ Phone #___________________Relationship______________________
Name__________________________________ Phone #___________________Relationship______________________
Name__________________________________ Phone #___________________Relationship______________________
Your child will not be released without prior written authorization to anyone not listed above. In the event you call a pickup authorization into the school because you are unable to submit your authorization in writing, we will use your personal
information from this packet to verify your identity.
_______________________________________________
______________________________
Parent’s Signature
Date
Authorization to Treat a Minor
This consent shall remain effective until ________________, of the year __________.
Medical Authorization
I (we) the undersigned parent, parents or legal guardian of __________________________________, a minor, do hereby
authorize and consent to any x-ray examination, anesthetic, medical or surgical diagnosis rendered under the general or
special supervision of any member of the medical staff and emergency room staff licensed under the provision of the
Medicine Practice Act, of a Dentist licensed under the provisions of the Dental Practice Act, and on the staff of any acute
general hospital holding a current license to operate a hospital from the State of Colorado Department of Public Health. It
is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care being
required but is given to provide authority and power to render care, which the aforementioned physician in the exercise of
his best judgment may deem advisable. It is understood that effort shall be made to contact the undersigned prior to
rendering treatment to the patient, but that any of the above treatment will not be withheld if the undersigned cannot be
reached.
List any restrictions:
Signature of Father, Mother, or Legal Guardian:
_______________________________________________________Date: _____________________
_______________________________________________________Date: _____________________
Child’s Birth Date: _________________________________
Last Tetanus Booster: ____________________
Allergies to Drugs or Food:
_________________________________________________________________________________
Any Special Medications or Pertinent Information:
_________________________________________________________________________________
_____________________________________________________
Preferred Hospital: _____________________________________Phone:_______________________
Child’s Physician: ______________________________________Phone:_______________________
Insurance Company: _________________________________________________________________
Policy Number: _______________________________________
Please read and initial each item in the box, then sign at the bottom.
Video Release
I understand the use of video is limited to those of educational quality and those that are age
appropriate. Videos are used for teaching purposes, special occasions and during bad weather. On
occasion full length children’s movies are viewed.
Nap Cot Authorization
I have discussed the nap routine with the staff and I have seen the cot/mat my child will sleep on. I
hereby give permission for my child to use the cots during nap time.
Field Trip
I understand that the children take walking field trips around campus. If field trips take children away
from campus, I will be notified and a special permission slip will be provided.
Authorizations
Sun Screen
I understand that sunscreen will be applied only with written authorization and instructions for
application. I will provide LMLC with sunscreen that is labeled with my child’s first and last name
along with Instructions for application.
Permission Releases
I hereby grant permission for my child_____________________________ to participate in all activities at
Little Mavericks Learning Center. These will include, but not be limited to, field trips and walks, cooking experiences,
evaluations, videotaping of classrooms, publicity photos connected with the program, and use of all play equipment in the
building.
I also understand the school will not be responsible for anything that happens as a result of false information
given at the time of enrollment. I understand the school will not be held responsible for a child who has not been signed
in when he/she arrives for the day.
In consideration of Little Mavericks Learning Center admitting my child into its program, I hereby for myself,
my heirs, administrator and assign, waive and release any and all rights to and claim of any nature against LMLC and
their organization, representatives, successors and assign for any and all injuries or damages of any nature which my child
may suffer in the program.
I also acknowledge that I have read and agree to the policies set forth in the Parent Handbook.
______________________________________
Parent signature
______________________________
Date
Tuition
Tuition is due at the time the monthly summer calendar is turned in.
Delinquent accounts are daycare accounts that have a balance remaining after day care tuition is due.
If a balance remains after the 15th of the month tuition is due, a child will no longer be able to attend Little Mavericks
until the balance is paid off.
Tuition Agreement
Any account that goes without a payment for 90 days will be sent to collections.
Late fee:
Late payment will result in a fee of $5.00 per day for each day after due date.
Return checks:
A $22.00 charge added to your account.
Late pick up:
All children must be picked up by 5:30pm. Little Mavericks charges a late fee of $5.00 for every fifteen minutes a child
remains at the center past the deadline The fee will be added to their next tuition bill.
By signing this agreement, I am stating that I have read and agree to all tuition policies
and procedures of Little Mavericks LEARNING CENTER.
______________________________________________
Parent’s signature
__________________
Date
Child’s Name_____________________________________________________
Indicate the time you would like your child at LMLC (example 8:00am-5:00 pm)
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
May
15
18
19
20
21
22
25
26
27
28
29
Tuition is per day
Toddlers $30.00
Total number of days (X) $30.00=__________
Preschool $25.00
Total number of days (X) $25.00=__________
Total Tuition: $______________
May’s calendar and payment is due by May 1, 2015
Child’s Name_____________________________________________________
Indicate the time you would like your child at LMLC (example 8:00am-5:00 pm)
June
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
1
2
3
4
5
8
9
10
11
12
15
16
17
18
19
22
23
24
25
26
29
30
Saturday
Tuition is per day
Toddlers $30.00
Total number of days (X) $30.00=__________
Preschool $25.00
Total number of days (X) $25.00=__________
Total Tuition: $______________
June’s calendar and payment is due by May 18, 2015
Child’s Name_____________________________________________________
Indicate the time you would like your child at LMLC (example 8:00am-5:00 pm)
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
1
2
3
7
8
9
10
13
14
15
16
17
20
21
22
23
24
27
28
29
30
31
Saturday
July
CLOSED
Tuition is per day
Toddlers $30.00
Total number of days (X) $30.00=__________
Preschool $25.00
Total number of days (X) $25.00=__________
Total Tuition: $______________
July’s calendar and payment is due by June17, 2015
Child’s Name_____________________________________________________
Indicate the time you would like your child at LMLC (example 8:00am-5:00 pm)
Sunday
Monday
Tuesday
3
4
10
11
Wednesday
5
Thursday
6
Friday
Saturday
7
August
CLOSED
Teacher Work Days
Tuition is per day
Toddlers $30.00
Total number of days (X) $30.00=__________
Preschool $25.00
Total number of days (X) $25.00=__________
Total Tuition: $______________
August Calendar and payment is due by July 18, 2015
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