GenerationsKnowledge & CareCenter, LLC
Enrollment Application
Child’s Name:______
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Child’s Address______
(Street)(City)(State)(Zip Code)
Home Phone or Cell#:______Date of Birth: ______Sex: Male Female
Name of School (if applicable): ______Date of Enrollment______
Circle day(s) to attend: Mon. Tues. Wed. Thurs. Fri:Arrival Time: ______Departure Time:______
PARENT/GUARDIAN INFORMATION:
Enrolling Parent/Guardian: ______
(Last Name)(First Name)(Middle Initial)
Relationship to Child: ______
(Cell Phone #) (E-Mail Address)
Address (If different from above): ______
(Street)(City)(State)(Zip)
Employer: ______Work Phone #:______Ext:______
Work Address:______City/State: ______Work Hours:______
Parent/Guardian:______
(Last Name)(First Name)(Middle Initial)
Relationship to Child: ______
(Home Phone #) (Cell Phone #)
Address (if different from above): ______
(Street)(City) (State)(Zip)
Employer: ______Work Phone #: ______Ext:______
Work Address: ______City/State: ______Work Hours: ______
Primary Residence: With Mother With Father Both Parents Guardian (Name):______
Parent’s Marital Status: Married Single Separated Divorced
If separated or divorced, who has legal custody? ______
May the non-custodial parent pick up the child? Yes No Name: ______
The child will be released only to the people on this application and the following persons:
Name:______Relationship to the child: ______Cell Phone #:______
Address:______Home Phone #: ______
Name: ______Relationship to the child: ______Cell Phone#: ______
Address: ______Home Phone #: ______
Generations Knowledge & Care Center, LLC
Enrollment Application (Continued)
Child’s Name: ______
(Last Name)(First Name)(Initial)
Child’s Physician: ______
(Name)(Address)(Phone #)
Hospital Preference: ______
Emergency Contact other than parents:
Name: ______Address: ______Phone #: ______
Name: ______Address: ______Phone #: ______
Any allergies, special needs, disabilities, physical limitations or any other thing which would limit the child’s participation in the program and/or activities: Yes No (If yes, please explain below):
______
______
Is the child potty trained? ______What does your child say when he/she wishes to use the toilet? ______
Does you child need help in: Dressing/Undressing ______Eating ______Washing Hands ______
Does your child have any special fears or problems? ______
Has your child been cared for by someone other than parents? Yes No (If yes, list name and relationship or Center’s Name)
1)______
2)______
Child’s Favorite toy(s): ______Favorite game(s):______
______
Parent Agreement
Generations Knowledge & Care Center will be open from 6:00 AM to 6:30 PM Monday – Friday.
I agree to pay in advance each week’s tuition that is due on Mondays unless a holiday falls on Monday. I am aware that no deductions are made for absences & holidays.
I am aware that a $10.00 bookkeeping fee will be charged each day for payments received after Monday.
I am aware that a late fee of $1.00 per minute will be charged for late pick-up beginning after 6:30 pm and an additional $5.00 per minutebeginning at 7:00 pm. Late fee payments are due at the time of pick up.
I agree to pay a registration fee at the time of enrollment to be renewed annually inAugust.
I am aware that this enrollment fee is non-refundable.
Signature of Parent/Guardian: ______Date: ______
Print Name of Signature: ______
GenerationsKnowledge & CareCenter, LLC
Medical Report
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Child’s Name: ______
Birth Date: ______Sex: ______
HEALTH EXAMINATION
1) ______A complete physical examination was given on ______
(Date)
2) ______A current examination was waived due to ______
MEDICAL HISTORY
Chicken Pox (Year): ______Scarlet Fever (Year): ______
T.B./T.B. Contact (Year): ______Frequent Ear Infections: ______
The State of Georgia Certificate of Immunization must be included in file for children ages 5 years and under.
Immunizations are up to date for age of child: Yes No
Laboratory and Other Tests (if indicated) Yes No
CHILD’S PHYSICAL LIMITATIONS, SPECIAL NEEDS OR DISABILITIES (For example: allergy, diabetes, heart disease, H.I.V., hepatitis, epilepsy or hospitalization in the past 12 months, and any medication prescribed for long-term continuous use.)
Allergies (List): ______
Routine Medications: ______
Dietary Restrictions: ______
Disabilities (Please be specific): ______
Others: ______
I, (physician name) ______examined this child on (date) ______. I find him/her to be in good physical condition, free of contagious and infectious diseases and may be admitted to a group child care facility. The child may participate in day care activities except as noted below:
______
______
*FORMS MUST BE COMPLETED AND SIGNED BY A PHYSICIAN WITHIN 30 DAYS OF ENROLLMENT