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