Early Childhood Learning Centers, Inc.
833 Hughes Place, Madison, Wisconsin, 53713, Tel. (608) 251-8127, Fax (608) 251-4427
www.eclcenter.org Provider No. 5000558055
E N R O L L M E N T A P P L I C A T I O N
Children are admitted without discrimination on the basis of age, race, color, handicap, political persuasion, national origin or ancestry.
Child’s Name:
Last First M. I. Nickname
Sex Birth Date Age Child’s Social Security No.: ______
Home Address: ______Street City State Zip
Phone ( ) ______
Legal guardian: Mother Father Both Mother & Father______Other______
Mother’s Name Phone ( ) Birth Date ______
Social Security No . - - Driver’s License No. ______
Street Address City State Zip ______
Employer Work Phone Work Hours: ______to ______
Street Address City State Zip______
E-Mail Address________
Father’s Name Phone ( ) Birth Date ______
Social Security No. - - Driver’s License No. ______
Street Address City State Zip ______
Employer Work Phone Work Hours: ______to ______
Street Address City State Zip______
E-Mail Address________
Family Physician: Address Phone ( ) ______
Preferred Hospital Address Phone ( ) ______
Emergency contact Relationship to Child ______
Address Phone ( ) ______
Authorized Escort Address Phone ( ) ______
Authorized Escort Address ______Phone ( ) ______
Medical Alert Information: List any special problems such as speech defects, feeding, behavior problems, mental or physical handicap, contagious diseases, illness, surgery, allergies, etc. ______
Special Needs or Restrictions/Letter From Doctor Date______
Bank
Name Address City Date Opened
Child’s Tuition: $ Payment: Weekly $ Bi-weekly $ Monthly $ Discount $______
Reason for Discount Type of Care: (circle) Full Time Part Time Pre Kindergarten B&A TODD. INF. S. CAMP
Days Attending (circle): Monday Tuesday Wednesday Thursday Friday
Arrival Time: ______(Not to Exceed 10 Hours Per Day)
Departure Time:
Breakfast ______
A.M. Snack ______
Lunch ______
P.M. Snack ______
Enrollment Date: Enrollment Fee $ Date Paid______ Date Started______Vacation#1Date:______Vacation#2Date: ______Extra Activities Dates ______
Elementary school Address ______
Phone( )______Transportation Needed To/From ______AM PM
How did you learn about Early Childhood Learning Centers?
Yellow Pages Newspaper Referral Sign Other ______
Authorization For Medical Treatment
If my child (child’s full name), should become ill or injured at the center, I understand that the center will: 1.) contact me immediately; and 2.) contact the person(s) designated if I cannot be reached. Should the center be unable to reach me and/or the person(s) designated, the center is authorized to contact my child’s physician and/or arrange for immediate medical treatment. The physician and/or medical facility are authorized to administer emergency medical treatment if necessary to ensure the health and safety of my child. I will accept responsibility for payment of medical services due to illness.
Signed Date ______Relationship______
Agreements:
1. The center will provide services for :______
2. I understand for this service the sum of $ shall be paid on the first day of attendance each week in advance. failure to pay by Wednesday will result in a $5.00 fee added to your fee. 3. I understand that failure to make payment by Friday of each week will result in termination of this service. the center manager is not authorized to extend credit.
4. Payment credit will not be given on a disputed payment without a signed cash receipt or canceled check. 5. Checks returned from the bank must be repaid in cash, plus a $15.00 handling fee within 24 hours. Checks will be returned when reimbursement is made. Parent will be put on a money order/cash only basis. for the next 30 days. A second returned check will place the account on a permanent money order/cash only basis. For an exception to these policies, permission for credit must be obtained from the office prior to Monday morning. the office is open 6:00 a.m. to 5:30 p.m. , Monday through Friday. The phone number is (608) 251-8127. Additional information will be requested at this time. 6. The annual enrollment fee of $45.00 is due at the time of enrollment and each January thereafter. If your child enrolls between January 1st and June 1st , your annual enrollment fee in January is $45.00. If your child enrolls between June 2nd and December 31st, your annual enrollment fee in September is $25.00. 7. Vacation time will not be given unless the child’ s annual enrollment has been paid in full. Day care, pre-school, and after school children are enrolled in the center on a regular weekly schedule and receive a discounted weekly rate for these programs. for this reason, no reductions in the weekly rate will be made for absences or for the following holidays: new years day, memorial day, fourth of July, labor day , thanksgiving day, or Christmas. Children in these programs, (except infants and toddlers), are entitled to two weeks absence each year, which can be used for vacation or sickness, without being charged. these must be taken as full weeks’ i.e., Monday through Friday, plus daily rate for days in center. the additional charges will not exceed regulae weekly rate. 8. When my child is ill, it is understood and agreed that he/she may not be accepted for care. 9. I agree to contact the center by 9:00 a.m. in the event of absence. 10. I understand that the center will administer medication prescribed by a physician with the written permission from the parent. 11. The provider and I have agreed on a plan for continuing communication regarding my child’s development, behavior, etc. 12. The center has my permission to take my child on foot, by bus, or car on field trips to various points of interest and for medical service. 13. I have received in writing these centers' policies pertaining to the admission, discharge, vacation, and discipline of children 14. I have been informed that a copy of the licensing rules for childcare centers is available at this center 15. The Center will not be responsible for any lost or stolen or damaged personal property. 16. The center reserves the right to dismiss any child. 17. The Early Childhood Learning Centers reserves the right to close the center for one week during the year if it becomes necessary. I will be paying $ hourly, weekly, bi-weekly, monthly, Monday (in advance.)
Signed Date______
Parent