COE Child other information form - coechildcareandacademy

“We understand that it takes a village to raise a child and we’re glad you chose COE to become part of your village”.

Step 1 of 10 - Child and Family Information

Child's Name(Required)

First Middle Last Name used by Parent

Child's Address(Required)

Street Address Address Line 2 City State Zip

Child's Date of birth(Required)

Child's Age(Required)

Child's Gender(Required)

Male

Female

Parent 1(Required)

First Middle Last

Parent 1 Address(Required)

Street Address Address Line 2 City State ZIP

Parent 1 Home Phone number(Required)

Parent 1 Cell Phone number(Required)

Parent 1 Email address(Required)

Enter Email Confirm Email

Parent 1 Email Address Type(Required)

Home

Work

Parent 1 Employer(Required)

Parent 1 Work phone number(Required)

Parent 2(Required)

First Middle Last

Parent 2 Address(Required)

Street Address Address Line 2 City State Zip

Parent 2 Home Phone number(Required)

Parent 2 Cell Phone number(Required)

Parent 2 Email address(Required)

Enter Email Confirm Email

Parent 2 Email Address Type(Required)

Home

Work

Parent 2 Employer(Required)

Parent 2 Work phone number(Required)

Does your child have any known allergies ?(Required)

Yes

Children with serious allergies must have an allergy action form on fiIe. Please see the director for the form to be completed by the child's physician prior to your child's first day.

For mild allergies, please describe the allergy and your child's reaction

Child's Doctor Name(Required)

First Last

Child's Doctor Address(Required)

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

Child's Doctor Phone Number(Required)

Child's Dentist Name(Required)

First Last

Child's Dentist Address(Required)

Street Address Address Line 2 City State Zip

Child's Dentist Phone Number(Required)

Hospital Preference(Required)

Medical Insurance Carrier(Required)

Policy Number:(Required)

Emergency Contact(Required)

Name

Relationship

Home Phone number

Work Phone number

Cell Phone number

In an emergency every effort is made to contact the child's parents (guardians) first. In an emergency when neither parent mor guardian can be contacted NC Child Care Rules require parents to list a minimum of 2 individuals who live in the Hillsborough, Durham or Chapel Hill area and have a local phone number to be contacted (parents cannot be included). We cannot list contact numerically.

Individuals to whom vour child can be released other than emergency contacts(Required)

Name

Relationship

Home Phone number

Work Phone number

Cell Phone number

Does this child have any special needs?(Required)

Yes

The Center of Excellence strongly supports including children with various needs into our classrooms. To ensure placement of your child, please answer the following accurately and honestly.

If yes, please explain

Does your child have a 1FSP?(Required)

Yes

Does this child have any other physical /behavioral issues ?

Parent 1 Signature(Required)

Date(Required)

Parent 2 Signature(Required)

Date(Required)

Center Administrator's Signature

Reserved for center Administrator

Date

Family Enrollment Agreement(Required)

I agree .

So that each parent understands Center policies, we ask that you read the following information
and sign this form indicating your agreement and understanding of the policies set forth.
1. Upon enrollment, a handbook will be furnished to each parent that will include general
regulations and procedures of the Child Care program. I understand any policy changes will
be given to me in writing.
2. I understand the Center of Excellence Child Care and Academy voluntarily follows
enhanced licensing requirements through our center policies and classroom practices. staff
education requirements and reduced staff to child ratios in our classrooms.
3. I understand that I am responsible for keeping the information in my child's file up-to-date
and in no way will hold the Center of Excellence Child Care and Academy responsible for
failure to notify me in case of emergency because of incorrect or out-of-date information.
4. I hereby agree that the Center and staff are released from liabilities arising from illnesses that
may be contracted by my child while on the premises of the Center of Excellence Child Care
and Academy. I fully realize that my child will be subjected to communicable diseases.
5. I give permission to the Center of Excellence Child Care and Academy to take my child on
field trips and places of interest. Announcements regarding field trips are normally posted
one week prior to the date of the trip.
6. I agree that my child may be outside the fenced area on occasions such as nature walks.
Infants and toddlers may take rides outside the fenced area in a Bye Bye Baby Buggy.
7. I understand the Center of Excellence Child Care and Academy participates in community
awareness activities and those individuals and/or community professional may come into my
child's classroom. My child may be photographed and/or video taped and newspapers,
television stations, newsletters, colleges and universities may use those images. If I choose
for my child not to participate in these activities I will provide a written statement to the
director.
8. I understand Center of Excellence Child Care and Academy's staff will take photographs of
my child to be displayed in the center. If I do not wish for my child to be photographed I
will provide a written statement to the director.
9. The Center of Excellence Child Care and Academy is not responsible for the loss of personal
property whether the loss occurs by theft, fire, or any other cause.
10. The Center admits children of any race, color, national and ethnic origin to all the rights,
privileges, programs, and activities generally accorded or made available to children at the
Center. It does not discriminate in the administration of its personnel or educational
policies, admission policies, or other programs.
11. As parents, we agree to bring any and all questions and criticisms to the person most directly
involved. If we have concerns regarding the care or program provided to our child, we agree
to make these concerns known to the teacher. If a satisfactory conclusion is not reached,
then we will contact the Child Care Director.
12. I understand my child may be withdrawn if my tuition is not paid in full by the 10th of the
month and I have not made a financial arrangement with the director or the assistant director.
1 3. Occasionally families ask to get in touch with their child's classmates, please check yes
if you will allow us to share your family’s information with other families in our
program. Check no if you do not wish to be included. Yes No
14. I have read and understand CEOCCA Wellness Policy as explained in the Parent Handbook.
15. I understand a copy of the Summary of NC Child Care Law is in the Parent Handbook.

16. If you are late picking your child up you will be charged a $30.00 late pick-up fee with an additional $1.00 for every minute after the contracted pick up time. If you are late more than THREE times in a month there will be an additional $20.00 charge included in the already late fee these fees will be added to your account and MUST be paid with/before next month's tuition. If you are not aware of your drop off and pick up times please see management.
I have read the enrollment agreement. By signing this agreement I am indicating my support and
agreement to the policies as stated in this agreement and the Parent Handbook. I understand I
will any policy changes in writing.

Parent 1 Signature(Required)

Date(Required)

Parent 2 Signature(Required)

Date(Required)

Upload the Summary of the North Carolina Child Care Law and Rules(Required)

Max. file size: 2 MB.

Do you need a transportation for your child ?(Required)

Yes

If yes please upload the filed and signed transportation permission form

Max. file size: 2 MB.

I, the parent or guardian of(Required)

Child's Name

Date of child's enrollment(Required)

Print name of parent/guardian(Required)

Name

Signature of parent/guardian(Required)

Date(Required)

Upload the filed and signed Child Income Eligibility Application(Required)

Max. file size: 2 MB.

Upload the filed and signed the Child Participant Enrollment Form(Required)

Max. file size: 2 MB.

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