Application for Admission – Community Child Care Center

Step 1 of 13

You only need to fill out the application upon enrollment notification.(Required)

I have been notified of enrollment

Date of Application

MM slash DD slash YYYY

Child's Full Name

First Last

Child's DOB

MM slash DD slash YYYY

Mother's Name or Guardian

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone #

Cell Phone #

Place of Employment

Employers Address

Employers Phone #

Work Hours

Father's Name or Guardian

First Last

Address (if different)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone #

Cell Phone #

Place of Employment

Employers Address

Employers Phone #

Work Hours

Transportation Plan:

My child will arrive and leave daycare at what times? (ex: arrive 8am and leave 6pm)

Emergency Information

I authorize the following to act on my behalf in the case of an emergency if I cannot be reached with the information I have provided.

Name

First Last

Phone

Address

Name

First Last

Phone

Address

Pick Up List:

I authorize the following to pick up my child from daycare.

Person(s) Authorized To Pick Up Your Child:

Name

Relationship

Person(s) NOT Authorized To Pick Up Your Child:

Name

Relationship

Household Information

Number of Siblings

Name

Age

Medical Information

Physican's Name

Phone

Office Address

Preferred Hospital

Consent(Required)

I do hereby agree to keep this application current. I will report all changes to the center as it realted to my job, address, phone numbers, and medical/shot records. I understand that it is my responsibility to provide this information in a timely manner.

Signature(Required)

For Parents With Children Over 1 Year Old

What are some of the ways your child plays with others?

Does your child usually get their way with others? Please explain

How does your child act if they don't get their way?

Is the entire family together for anytime during the day?

How does your child act if they don't get their way?

If your child refuses to eat, what do you normally do?

What food(s) does your child like to eat?

What food(s) does your child refuse to eat?

What food(s) is your child ALLERGIC to?(Required)

If your child has an allergy to milk or milk products you must provide a medical report from your child’s doctor.

What is your child's sleeping habits and attitude towards going to bed?

Is your child potty trained?

Do they go without asking?

How does your child let you know they have to go to the bathroom?

Can your child dress themselves?

Can you understand your child's speech?

Check all that apply. My child is:

Active

Quiet

Thin or Average in Weight

Overweight

Tall

Short

Average Height

Unfriendly

Other

Other:

If this application is for a child under 1 year of age; Formula, Bottles, etc must be prepared in advance unless it is being provided by the center.

Please use this space below to provide us with any other information you find important.

Dear Parents,

We now offer Iron-Fortified formula, baby food and snacks to our infants at no additional cost. Please send in 4 empty bottles daily, labeled with your child’s name. Your child’s caregiver will discuss with you when you feel best to transition your child from formula to baby food and then table food. A weekly menu is posted in the classroom for you to view. If you have any additional questions please don’t hesitate to contact Mrs. Blue or Mrs. Leach

Please indicate which items you wish for your child to have.

Formula

Baby Food & Cereal

I wish to decline in participating in this program currently.

Consent

By signing below, I confirm that I have been offered the food program and have received a copy of the Infant Meal Pattern

Signature

Community Child Care Media Waiver

As a United Way Agency partner, we are asked to participate in social media activities, posters, and advertisements. Please check and sign below if you give permission for your child to participate in the following ways:

Video

Photos

Posters

Social Media Post

I do not give permission for my child to participate in any media.

Child's Name

First Last

Parent Signature

State of Compilance

Any person who applies for or receives services provided by Community Child Care, Inc, may file a complaint if he or she believes they have been treated differently because of race, color, creed, national origin, or religion. Complaints must be in writing with the title VII representative for Community Child Care (the director), or the title VII with the coordinator with the Department of Human Services.

Permission to Release Information

I give Community Child Care Inc. Permission to: Obtain or give to the Department of Services, Health Department, Public School System, and all other service agencies involved in giving care to your child or children pertinent social, medical, or other information concerning my child or children who are enrolled in the center. In granting such permission I understand that such information will remain confidential to all other parties and will be used only to give my child or children the best available professional assistance or to provide an advertisement for the center.

My child will receive the necessary immunizations required by the State of Tennessee while they are at the center for their health and well-being of others

I give Community Child Care permission to give medication to my child, as presribed by their doctor and documented by me on the medication form in the front office.

If emergency care is deemed necessary and I can't be contacted and none of my emergency contacts that are listed in my file can't be contacted through normal procedures, I give the staff member in charge at Community Child care to act on my behalf in granting permission for my child to receive emergency treatment or surgery at the nearest approved medical facility.

In granting the above permission, I understand that the center is not an agency or of a representative of any medical facility. Community Child Care assumes no liability for any treatment or lack of treatment performed by any medical professional or facility.

I understand that if the center goes on a field trip (off-site) I will receive a special authorization form to grant permission for my child to attend.

Signature(Required)

Parent/Caretaker Acknowledgement and Consent to an Overage Fee

I want to enroll my child(ren) in the Community Child Care program which is licensed by the State of Tennessee. I understand their rates are higher than the rate the State of Tennessee pays for a child in the Child Care Certificate Program. I understand that the difference will not be paid by the State of Tennessee and that if I enroll my child in this center, I will be responsible for any difference. This difference is called an overage fee. There will be an overage charge for each child that is enrolled. By signing this agreement, I understand I will be expected to pay this overage fee. This agreement is between the childcare provider and myself. The above consent has been explained to me and I wish to continue the enrollment process.

The following child(ren) will be attending Community Child Care once all signatures, documents, and fees are paid and turned in.

Child's Name

Date of Birth

I know if I have a co-pay fee with the Department of Human Services, the co-pay fee must be paid to remain eligible for the Child Care Certificate Program. If I do have a co-pay fee, this must be paid in addition to the overage fee. All payments must be paid to Community Child Care.

Termination of Child Care Services

We are an agency that strives to work closely with families to ensure a professional and safe atmosphere. We realize financial hardship will come and situations may cause behaviors to represent a negative outlook. Please be advise that it is at the discretion of the Executive Director as to whether childcare services can continue. A family can be dismissed from our center due to late fees, use of profanity, disrespect, breach of contract, threats, and any situation that my bring harm to the center and any family involved. I have read and understand the termination policy outlined by Community Child Care.

Signature

Grievance Policy

If any parent has a grievance with Community Child Care, you may present those grievance es to the director. If you are not satisfied with the action of the director, you may take your grievance to the board. The decision of the board is final. The process will be no longer than 30 working days from the day filed. I have received, read, and understand the Community Child Care Policies. I have received, read, and understand the Grievance Policy. I have received a copy of the Licensing Summary, that is to be read at my convenience. I have given my permission to release information to other agencies who are involved in serving my child(ren). I have received, read, and understand the 1964 Civil Right Compliance Statement. I agree to comply with the policy at all times.

Signature

Community Child Care Late Pick Up Policies

If your child has not been picked up by 6:00pm you will be charged $5.00 per minute until they are picked up. This fee must be paid before your child can return to the center the next business day. I have read and understand the policies set forth by the Community Child Care administration.

Signature

Inclement Weather

In case of inclement weather, Community Child Care will always follow FSSD school closings and altered schedule, unless otherwise stated. Please watch your local news and follow us on Facebook (Community Child Care Center of Franklin TN) to monitor the schedule.

Signature

State of Tennessee | Department of Human Services

Personal Safety Curriculum Notification Form

Signature for Personal Safety Curriculum Notification Form

Influenze Information Notification Form

Signature for Influenza Information Notification Form

Has your child ever had:

Ear Infections

Nose problems (sinus infections, nose bleeds)

Eye problems (blurry vision, need to wear glassses)

Hearing Problems

Mouth or throat problems (Strep throat, swallowing problems)

Diarrhea (have frequent and runny bowel movements/poop)

Constipation (problems having a bowel movement/poop)

Problems peeing (bed wetting, pain when peeing)

Were there any problems with pregnancy or giving birth?

Growing pains (bone or body pains due to growing

Signature