Lil’ Rams 2014-2015 Enrollment Application Please fill in application completely and legibly CHILDREN’S RECORD Child(ren)'s Name: Birthdate(s): Enrollment Date: Gender: Male Female Parent or Guardian's Home Address and Employment Address: FATHER (or Guardian): Name: Employer: Address: Address: City, State, Zip: City: Home Phone Phone: Cell: Email: MOTHER (or Guardian): Name: Employer: Address: Address: City, State, Zip: City: Home Phone Phone: Cell: Email: Person(s) to Whom the Child(ren) may be Released by the Caregiver: (If no one, please write "none") Name: Address: Home Phone: Cell Phone: Work Phone: Cell Phone: Work Phone: Name: Address: Home Phone: Person(s) Who Will Take Responsibility for the Child(ren) in an Emergency When the Parent/Guardian Cannot be Reached: (ONE NAME MUST BE GIVEN) Name: Address: Home Phone: Cell Phone: Work Phone: Cell Phone: Work Phone: Name: Address: Home Phone: Consent to Contact Physician in Emergency: In the event I cannot be reached to make arrangements, I hereby give my consent to RSF to contact Doctor Name of Physician Phone Number Address City and, if necessary, take my child(ren) to the following doctor(s), clinics or hospitals Signature of Parent/Guardian Date Transportation Permission: I hereby give RSF permission to transport or arrange transportation of my child . Name of Child(ren) I understand staff will insure that my child(ren) is placed in appropriate safety restraint as indicated by Nebraska law at all times the vehicle is in motion. Signature of Parent/Guardian Date Medication Competency Statement: I, have determined RSF competent to give or apply medication to my child(ren). Parent/Guardian Signature of Parent/Guardian Date Photograph/Filming Permission: I give permission for to be photographed/filmed participating Name of Child(ren) in activities at Lil’/Tiny Rams. I understand that such photos may be used occasionally in the media to publicize activities for the Lil’/Tiny Rams program. Signature of Parent/Guardian Date Field Trip Permission: I give permission for ____________________________________________ to participate in supervised activities away from the Name of Child(ren) Lil’/Tiny Rams site. This includes permission for my child to be transported by bus/van for field trips. I understand that I will be notified in advance of any activities off the site premises. Parents are required by state law to supply Lil’/Tiny Rams with a federally approved child safety seat. Signature of Parent/Guardian Date Swimming Permission: Specifically, I do hereby give permission for to go swimming with the RSF. Name of Child(ren) I understand that certified lifeguards, the RSF’s Directors, Assistant Directors and Support Staff will supervise my child. I agree to hold the RSF harmless of any accidental injury caused out of the activity so long as it was not a foreseeable incident, which could have been prevented. I understand that it is my responsibility to make my child aware of their swimming abilities and any restrictions. Pool locations included but are not limited to: -Mockingbird Hill Community Center, 10242 Mockingbird Drive -Oak Heights, 10205 U Street -Karen Western 6288 H Street Signature of Parent/Guardian Date Any health problems which caregiver should know: Medication/Allergies, if any: Special Needs or Accommodations, if any: Certification of Immunizations TYPE OF VACCINE VACCINE Polio OPV or IPV DTP/DT/DTaP Diphtheria Tetanus Pertussis Tdap Dos e Normal Schedul e 1 2 mo. 2 4 mo. 3 6-18 mo. 4 4-6 yrs. 1 2 mo. 2 4 mo. 3 6 mo. 4 15-18 mo. 5 4-6 yrs. 1 11-18 yrs. 1 2 mo. 2 4 mo. Date Given Mo. Day Yr. DOCTOR OR CLINIC ADMINISTERING Td/Tetanus and Diphtheria Hib Haemophilus influenzae b 3 4 M-M-R 1 6 mo. 12-15 mo. 12-15 mo. 2 Hepatitis A 1 2 Hepatitis B 1 2 3 Varicella Chickenpox date of disease 1 12-18 mo. 2 Meningococcal Conjugate 1 PCV Pneumococcal Conjugate 1 2 mo. 2 4 mo. Rotavirus 3 6 mo. 4 12-15 mo. 1 2 mo. 2 4 mo. 3 6 mo. I certify that the above information is correct to the best of my knowledge. Signature of Parent/Guardian Date Please circle 2014-2015 school year building: Blumfield Mockingbird Karen Western Seymour Meadows Wildewood Circle child’s Enrollment Status: Mornings $44.00 per week Afternoons $44.00 per week Full Time $56.00 per week Early Release (1:30-3:30pm) $11.50 per week Controlled Access: THIS IS FOR NEW FAMILIES ONLY- Cards for existing families will remain active. For added security all of the buildings in the Ralston School District have a controlled access system. For families enrolled in the Lil’ Rams program each family will be issued a card to gain entrance to their child’s elementary school. Please indicate number of cards needed . *Each family may have up to 2 cards at no cost. Who will the card owner(s) be: Extra cards and replacement cards are $10 each. This cost will be added to your Tuition Express account on the next scheduled deduction. Signature of Parent/Guardian Date RALSTON SCHOOLS FOUNDATION 2014-2015 Contract I have read all of the contents in the Lil’ &Tiny Rams Parent Handbook, revised January 2014. I, by signing this form, understand and agree to the terms and rules of the Ralston Schools Foundation Lil’ & Tiny Rams child care program. I understand that tuition is based on enrollment status, not actual attendance. Tuition will be drafted from a checking/savings account of my choice each and every Friday. The first deduction for 2014-2015 will be on Friday, August 15, 2013. The last tentative deduction for 2014-2015 will be on Friday, May 22, 2014. Parent/guardian may terminate contract by giving two weeks written notice in advance of the ending date. Payment by the parent/guardian is due for the notice period, whether or not the child will be attending Lil’ Rams. ____________________________________________ ___________________ Signature of Parent/Guardian Date $35.00/child Non-refundable registration fee must accompany this child enrollment form. I have attached the registration fee with the enrollment application. I would like to have the registration fee pulled from my Tuition Express account on the next scheduled deduction. Hop aboard the Tuition Express and never write a check again! As your childcare provider, we are excited to offer you the convenience of automatic tuition payments through Tuition Express. You’ll no longer need to write a check or remember your checkbook when you’re picking up your child at the end of a hectic day. Your payment will be safely and securely processed by Tuition Express, giving you peace of mind that your tuition has been paid on time! It’s easy to enroll and even easier to participate. You’ll be joining tens of thousands of parents nationwide who enjoy the ease and convenience of Tuition Express. To learn more about Tuition Express, automatic payment notifications or reviewing your payment history, please visit www.tuitionexpress.com. For Bank Account Authorization, complete and return to center management. ELECTRONIC FUNDS TRANSFER AUTHORIZATION I (we) authorize ______________________________________ , (called “CENTER” in this Authorization) to initiate debit entries to my (our) Checking or Savings Account indicated below at the depository financial institution indicated below (called “DEPOSITORY” in this Authorization). I (we) authorize CENTER to withdraw sufficient funds to pay my (our) regular childcare tuition and/or other childcare related fees that are due and payable. I (we) authorize CENTER to use the third party sender, Tuition Express* to process all payments. I (we) acknowledge that the origination of Automated Clearing House (ACH) transactions to my (our) account must comply with the provisions of United States Law. Credit Union Members: Please contact your Credit Union to verify account and routing numbers for automatic payments. __________________________________ ______________________ _______________________________________________ Your Name Phone # DEPOSITORY - Bank or Credit Union Name __________________________________________________________ ______________________________________________ Address Bank or Credit Union Address __________________________________________________________ ________________________________________________ City State Zip City State Zip Type: ͗ Checking ͗ Savings __________________________________________________________ ________________________________________________ Routing Transit Number (see sample below) Account Number (see sample below) This authorization will remain in full force and effect until I (we) notify the CENTER in writing of its termination in such time and in such manner as to afford Tuition Express and DEPOSITORY a reasonable opportunity to act upon it. Notices must be received at a minimum of 5 business days in advance of the termination date. _______________________________________ ______________________________ Signature Date Record Retention Notice: The child care provider shall retain all parent (client) authorization forms in a secure location for a period of two years from the date of client withdrawal from the Tuition Express™ program. *Tuition Express is an assumed business name of Blum Investment Group, Inc. Routing Transit Number Account Number Check Number Please attach a copy of a voided check here. Deposit slips not accepted.
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