SusannaWesleySchool-Age Programs

7433SW 29thSt. Topeka, KS66614

785-478-3703

EnrollmentApplicationforSchoolYear2016-2017

~PersonalInformation~

ChildName: Sex: DateofBirth:

StartDate: DaysAttending:_ HoursAttending:

Address: Phone:

Street City ZipCode

Mother/Guardian: HomePhone: CellPhone:

HomeAddress:

Street City ZipCode

HomeE-MailAddress:_

Occupation: PlaceofEmployment: WorkPhone: _

WorkAddress: _

Street City ZipCode

WorkE-MailAddress:_

Father/Guardian: HomePhone: CellPhone:

HomeAddress: _

Street City ZipCode

HomeE-MailAddress:_

Occupation: PlaceofEmployment: WorkPhone:

WorkAddress:

Street City ZipCode

WorkE-MailAddress:

~E-MailAddress~

Pleaselistane-mailaddress(s)thatyouwouldlikeustouseforcorrespondence:

~PublicityRelease~

Igrant permissionformy child tobeinvolved inpublicityfor SusannaWesleySchool-AgeProgram,which mayinclude:

(Pleasecheckanyorallofthoseyouconsentto): ForCenterUseOnly Other

Audio/VisualRecording Television

PhotographsforPictureCD Newspaper

(over)

~MedicalConditions~

Doesyourchildhaveanydrug,food,orpetallergiesoris thereanyothermedicalconditionswe shouldbe awareof:

~LocalEmergencyPick-UpList~

Person(s)allowedtopickupyourchildwithparentalconsent,orto contactin caseofinabilitytolocateparent(s):

1. Name: Relationship:

Address: City: _Zip:

HomePhone: WorkPhone: CellPhone:

2. Name: Relationship:

Address: City: Zip:

HomePhone: WorkPhone: CellPhone:

~DoctorandHospitalInformation~

NameofDoctor:

Address:_ City:_ Zip:_

PhoneNumber:

NameofHospitalPreferenceincaseofemergency:

HealthInsurancePolicyName: PolicyNumber:_

Icertifythatallinformationonthisenrollmentformiscorrect:

ParentSignature: Date:

Anon-refundable one-timeregistrationfeeof$55mustaccompany thisapplication.

Howdidyouhearaboutus?

CapitalJournal Friend _PhoneBook/whichone

SignOutFront

SusannaWesleySchool-AgeProgram

Beforeand AfterSchoolCare

Contract

EffectiveforSchoolYear

2016-2017

I, ,contractforserviceswithSusannaWesley

BeforeandAfterSchoolProgramformychild(ren)asspecifiedbelow:

Address

DaytimePhone HomePhone

Child’sName Grade Rate$

Child’sName Grade Rate$

Child’sName Grade Rate$

MonthlyFees

Mychild(ren)’senrollmentstatuswillconsistofthe following: IndianHillsor Farley

BeforeSchoolOnlyAMArrivalTime Departureat8:40

AfterSchoolOnlyPMArrivalTime3:45Departureat

Beforeand AfterSchoolBothAM ArrivalTime Departureat8:40

PMArrivalTime3:45Departureat

DropInorBreakDay

Carewillbegin(date):

(Over)

AdditionalFeeInformation:

**LateDepartureFees:Itistheprogram’spolicyto chargeanadditionalfee forlatepickupof$2per minuteper childwithnograceperiod.This feeispayablethenightofthe occurrenceor the followingmorning.If fee is notpaid yourchild(ren)willnotbeallowedtocomeuntilpaymentismade.

**ReturnCheckFee: Theprogram’spolicyisto chargea fee of$40.00forreturnedchecks.Aftertworeturnedchecks, cashier’s check ormoneyorderwillberequiredforpayment.We no longer accept cash for payments.

**LatePayment:Checksareduebythe fifthofeachmonth.Afterthefifth,a $20.00latefeewillbeassessed.Failure topayfeeswhenduemayresultinimmediateterminationofservices,unlessotherarrangementsaremade.

**Drop-inPolicy:Ifyouneedcareona daythatyourchildisnotcurrentlyenrolled,authorizationmustbegivenbythe

Director/Administratorand islimitedtospaceavailable.Drop-inCareis$15.00persession.

**BreakDays: Parentsmaysigna breakdaycontractfordaystheirchild(ren)willattend.BreakDaysaredaysinwhich theschoolisoutofsession.Theadditionalfeeforthesedaysis$30.00perchildif signedupbydeadline.

ContractedMethodof Payment

Iagreeto paythecontractedfeeasstatedonthiscontract.Pleaseinitialhere: Checkallthatapplyand fill intheamountinthespaceprovided:

Semi-Monthly: (Dueonthe1standthe15thofeachmonth): $

Monthly: (Dueonthe1stdayofeachmonth): $

DropIn:$15.00persession

PerBreakDayContract

Checkhereif youareinterestedinreceivinga receiptforpayments.Allreceiptswillbee-mailed.

Bysigningthiscontract,

 IacknowledgethatIhavereadtheSusannaWesleySchool-AgeHandbookpostedontheSusannaWesleyUnited

MethodistChurcheswebsite

 Iagreeto completeandreturntherequiredformsbeforeattendanceatSusannaWesleycanbegin.

 IunderstandthatIam to keepSusannaWesleyupdatedonanychangestomyEnrollmentApplicationandormy

Contract.IalsounderstandthismaymeanfillingoutanewEnrollmentApplicationorContract.

Ialsounderstandthatanychangeinenrollmentmustbeapprovedbythe Director/Administratorandmustbe accompaniedbya newEnrollment/ContractforFeesform.Anychangeinenrollmentrequiresa two-weekwrittennotice periodregardlessofchild’sattendance.Tuitionpaymentforthelasttwoweeksneedstobegivenattimeofnotice. SusannaWesleyreservestherighttoterminate thiscontractatanytimeandfor anyreason.

THEPROGRAMRESERVESTHERIGHTTOINCREASEFEESUPON30-DAYNOTICE.

Mother’sSignature: Date:

Father’sSignature: Date:

**BothMotherand Father’ssignaturesarerequiredto completeenrollment.PleasespeakwithAdministratorforspecial circumstances.

CCL.358 KansasDepartmentof HealthandEnvironment

Rev.1/2014 Bureauof FamilyHealth

ChildCareLicensingProgram

1000SWJackson,Suite200

Topeka,KS 66612-1274

Phone:(785)296-1270 Fax(785)296-0803

Website:

HEALTHHISTORYFORCHILDRENANDYOUTHATTENDINGSCHOOLAGE PROGRAMS

AsrequiredbyK.A.R.28-4-590(d) (1),eachoperator shallobtainahealthhistoryforeachchildoryouth,onaformsuppliedbythe department orapprovedby thesecretary. Eachhealthhistory istobemaintained inthechild’soryouth’sfileonthepremises. As requiredbyK.A.R.28-4-590(d)(2),eachoperatorshallrequirethateachchildoryouthattendingtheprogramhas currentimmunizations as specifiedinK.A.R.28-1-20orhasanexemptionforreligiousormedicalreasons.

CompleteoneformforeachchildoryouthattendingtheSchoolAgeProgram.

05/31/2016

FirstandLastNameoftheChild’sorYouth’sMotherorGuardian

Mother/Guardian’sHomeStreetAddress / City / ZipCode / HomePhone#
( )
Mother/Guardian’sWorkPlaceNameStreetAddress / City / ZipCode / WorkPhone# ( )

FirstandLastNameoftheChild’sorYouth’sFatherorGuardian

Father/Guardian’sHomeStreetAddress / City / ZipCode / HomePhone#
( )
Father/Guardian’sWorkPlaceNameStreetAddress / City / ZipCode / WorkPhone# ( )

NamesandagesofotherchildrenintheChildor Youth’sFamily(Attachadditionalpageif needed.)

Person(s)authorizedtopickup theChildor Youthin
caseofemergency.Includefirstand last nameand
StreetAddress.Attachadditionalpageifneeded.
1. / City / ZipCode / PhoneNumber(during
programhours):
2.
3.
Firstand LastNameof PhysicianStreetAddress / City / ZipCode / PhoneNumber
( )

NameofHospitalPreferencein caseof emergency.

Yes / No / N/A / Completethefollowinginformationaboutmedicationsfor thischildoryouth.
Willthis childoryouthneedto takeanynonprescriptionorprescriptionmedicationduringtheirtimeat the
program?
If yesabove,istheresignedpermissiononfile?
Circleanyofthefollowingconditionsordifficultiesthataffectthis childoryouth.
Allergies / Frequentsorethroats/colds / EarInfectionsorAches / HeartorLungConditions
SkinProblems / Asthma / Headaches / Diabetes
Vision / Speech/Communication / Hearing / Emotion/Behavior
Other:Pleasedescribe.

Ifyoucircledanyoftheaboveconditions,pleaseprovideadditionalinformationthatwillhelpthestaffmembersmeetthe child’soryouth’sneedswhileattendingtheprogram.(Attachadditionalpage,if needed.)

Provideadditionalinformationaboutyourchildoryouththatmightaffecthim/herwhileatthe SchoolAgeProgram includinganyspecialneeds,restrictionsto activities,majorchangesathomeorspecialinstructions.(Attachadditional page,ifneeded.

Completethefollowinginformationaboutthischild’soryouth’simmunizationstatus.

PleasegivedatesinthespacebelowforALLimmunizationseriescompletedbythischildoryouth.RecordMM/DD/YYYY.

1 / 2 / 3 / 4 / 5
DPT,DT*,TD(*DTonlyif childisallergicto DTP) / / /
/ /
/ /
/ / / / /
/ /
/ /
/ / / / /
/ / / / /
/ / / / /
POLIO
MMR
Single Dose Only / RUBEOLA(MEASLES)
MUMPS / / / / / /
RUBELLA(GERMANMEASLES) / / /
/ /
/ /
/ / / / /
/ /
/ /
HIB(HemophilusInflu.B) *RECOMMENDED / / /
/ / / / /
HBV(HepatitisB Vaccine) *RECOMMENDED
VAR(Varicella-ChickenPox) *RECOMMENDED

PrinttheFirstandLastNameofthePersonCompletingthisHealthHistoryform Relationshiptothe

Child/Youth

DateCompleted

IftheHealth Historyformwascompletedbya personotherthanaParent/Guardian, whoprovidedyouwiththisinformation?

Whatis thatperson’srelationshipto thechild/youth?

I attest,underpenaltyofperjury,thatto thebestofmyknowledge,the informationprovidedon thisformis true andcorrect. Signatureofpersoncompletingthisform DateSigned

CCL010Kansas Department of Health andEnvironment

Rev.6/2015Bureau ofFamilyHealth 1000 SW Jackson, Suite200

Topeka, KS 66612-1274

Child Care Program: (785) 296 -1270 Fax: (785) 296 -0803 Website:

AUTHORIZATION FOR EMERGENCY MEDICAL CARE

Written permission for emergency medical treatment must be on file at the facility. Consult with the local emergency medical facility to be sure this form is acceptable. Reference K.A.R. 28-4-127(b)(1)(A). School Age Programs reference K.A.R. 28-4- 582(e)(2).

Name of facility exactly as stated on the license.
Susanna Wesley School Age South / License #
0057315-008

Iherebyauthorize SWCC Program Director(Name of individual/staff member)and/or

SWCC Staff(Name of individual/staff member) who is (are) representative(s)oftheabovenamedfacilitytogiveconsentforanyandallnecessaryemergencymedicalcareformychildoryouth

(FirstandLastNameofChildorYouth)whilesaidchildoryouthisinsaidfacility’s

custody between thedatesof 08/16/2016and 05/25/17.

MM/DD/YYYYMM/DD/YYYY

Signature of Parent or Guardian / Date Signed
Witness to Parent’s or Guardian’s signature if required by the local hospital or clinic. / Date Signed

Notarization of Parent’s or Guardian’s signature if required by local hospital or clinic.

------

List any known allergies or other information about the medical status of this child or youth pertinent in case of emergency:



Is child covered by health insurance? Yes No If yes, complete the following:

Health InsurancePolicyNamePolicyNumber MedicalAssistanceProgram CardNumber Military Medical Care I.D.Number

If known, date of last Tetanusinoculation:

THE MEDICAL RECORD/ASSESSMENT FORM (OR HEALTH STATUS HISTORY FORM FOR SCHOOL AGE PROGRAMS) AND THE AUTHORIZATION FOR EMERGENCY MEDICAL CARE MUST BE TAKEN TO THE EMERGENCY ROOM. BOTH FORMS MUST ALSO BE IN A VEHICLE WHEN THE CHILD OR YOUTH IS TRANSPORTED BY THEFACILITY