Application

“An Early Step toward a Godly Walk”

Child Information

Child’s Name:                                                                                                                                 Date:                                                                  

Preferred                                        First                                       Middle                                          Last                                                  

Child lives with (name)                                                                 Relationship                                                                                       

Enrollment Date          /             /             DOB                 /             /             Child is Male                   Female                               

Child’s Social Security #                                        Hospital Preference (please, circle one):  Baptist / Forsyth

Known Allergies:                                         

Parent/Guardian

Mother/Guardian Name: First                                Middle Initial              Last                                    DOB              /        /   

Home Address                                                                                              City                                      State                  Zip           

Employer                                                                                          Work Address                                                                                              

Home Telephone                        Work Telephone                                          Cell                                      Email                      

Social Security #                                                        Driver’s License #                                                        State                     

Marital Status: (circle) Married             Single                 Divorced            Separated                       Widowed               

Father/Guardian: First                             Middle Initial                     Last                                      DOB                 /             /   

Home Address                                                              City                      State                                  Zip                                           

Employer                                                                                          Work Address                                                                                              

Home Telephone                        Work Telephone                                          Cell                                      Email                      

Social Security #                                                        Driver’s License #                                                        State                     

Authorized Release & Emergency Contact Information

Your child will only be released to the person above and those authorized below. Legal authorities will be contacted if your child is left at the school longer than hour after the daycare closing time. If the person listed below is also to be used as an emergency contact, please check the box on address line.

Relation                             Name                                                                   Home#                               Work#                                    

¨Emergency Contact       Address                                                                                                                                                       

Relation                             Name                                                                   Home#                               Work#                                    

¨Emergency Contact       Address                                                                                                                                                       

Relation                             Name                                                                   Home#                               Work#                                    

¨Emergency Contact       Address                                                                                                                                                       

Relation                             Name                                                                   Home#                               Work#                                    

¨Emergency Contact       Address                                                                                                                                                       

Relation                             Name                                                                   Home#                               Work#                                    

Person(s) not authorized to pick up child                                                                                                                                             

*Documentation such as custody papers should be attached if a parent is not allowed to pick up a child.

                I agree to receive information from Immanuel Baptist Church thru phone calls, mail, visits, or email for the enrichment of my family.

“An Early Step toward a Godly Walk”

Child’s name                                                                                   Date Enrollment                                                                                        

Weekly Schedule                       Monday            Tuesday           Wednesday                     Thursday                         Friday

Arrival Time                                                                                                                                                                                                                  

Departure Time                                                                                                                                                                                                         

*(Note) the weekly schedule is intended to represent a typical week and will only be used to assist with teacher scheduling. We realize that actual schedules will vary.)

Medical Information

My Child’s Pediatrician/physician is                                                                                          phone #                                                                

Address                                                                                                                                                                                                                              

My Child’s Dentist                                                                                                                          phone #                                                                

Address                                                                                                                                                                                                                              

My child has health insurance coverage      yes         no           Insurance Company                                         policy#                                 

                An allergy to a medicine, food, plant, or insect toxin.

                A condition or fear that may require special care, procedures, services, medication, or diet.

                A physical, mental, or developmental disability that would prevent my child from participating in the daily program.                                       .

Please explain special need, condition, fear, or allergy:                                                                                                                                                                                                                                                                                                                                                                                         

Does your child have a IEP/PEP if so we would like to receive a copy for our record  Yes                        No                                         

                (Initial) If your child has a temperature 101 degrees or higher, or any symptom of a contagious disease or infection, you must make other child care arrangements. In most cases, we ask that your child remain at home at least 24 hours after leaving the school because of an illness. Re-admittance is at the discretion of the director.

Medical Authorization

_____(initial) I agree that IBCD staff may authorize the physician of their  choice  to provide emergency treatment in the event that neither I nor our family physician can be contacted immediately. IBCD agrees to provide transportation to an appropriate medical resource in the event of an emergency and will not administer any drug or medication without specific instructions from the physician. In the event that such an accident or illness, all medical expenses incurred are my responsibility. I release IBCD and all of its employees, officers, directors, servants, and agents form liability incurred as a result of any act they may perform on behalf of my child.

Delivery of Students

_____(initial) I agree that when delivering my child to school, that I or the person I have authorized to drop off my child, will personally deliver my child to his/her teacher or the staff person in charge. I further agree that when picking up my child, I or the person I have designated will personally come into the school and sign the child out.

Medial Forms

                (Initial) I agree to complete Childs Medical Report within 30days of enrollment.  I agree that I will keep all shot records updated and given to office personnel. I also agree to keep my child shot records current with office personal.

 

 

 

SIDS

                (Initial)I have received a copy of the Safe Sleep Policy (SIDS) policy. The policy has been discussed with me and all my questions have been answered.  I understand all procedures are for the safety of my child while at IBCD. I understand that I can request an alternative sleep position waiver for my child in the office.

Activities Planned outside the fenced in area of the daycare

                (Initial)I do            I do not                  give permission for my child to participate in activities planned outside the daycare’s fenced area.

Swimming/Water Related Activities

                (Initial) I do           do not                    give my permission for my child to participate in water related activities.

Photo/Internet Authorization

                (Initial) I do           do not                    give my permission for my child to photographed or videotaped by IBCD. I understand that the photographs will be used to document my child’s participation in various school activities and could be used for public display to the other children, parents, and teachers.

Discipline Policy

                (Initial) I have received a copy IBCD’s discipline policy. The policy has been discussed with me and all my questions have been answered.  I understand that I will be consulted for advice and/or suggestions of other possible disciplinary actions for my child, if necessary.

Child and Abuse/Neglect

                (Initial) As child care provider, IBCD is mandated by the state law to report any cases where there is reasonable cause to believe that a child has been neglected, exploited, deprived, sexually assaulted, sexually exploited, physically injured or suffered a death by other than an accidental means by a parent or caretaker, to the proper authorities.  IBCD will cooperate fully with the authorities in the investigation of all such cases.

Confidentiality Statement

                (Initial) Information pertaining to your child is considered confidential and will not be released by IBCD to third parties without first obtaining your written permission. However it may be necessary to share relevant information relating to your child’s family situation, medical status and behavioral characteristics with authorized members of the state child care licensing agency or with persons authorized by the state licensing regulations or law to receive such information.

Change of Status

            (Initial) I agree to notify IBCD immediately of any changes that occur in the information provided in this enrollment application including work and home address, phone numbers, physician’s name, living arrangements, health information, emergency contacts.

NC Child Care Law and Rules

                (Initial) I have received a copy of “NC Child Care Law and Rules” as published by the Division of Child Development in my enrollment materials.

Handbook Policy & Payment Fees

                (Initial) I have received a copy of IBCD’s Handbook policy & Payment Fees. The policy has been discussed with me and all my questions have been answered. How did you hear about us? Circle One      Yellow Page               Radio              Newspaper                 Agency

Parent Referral (name)                                                                      other                          

Has your child previously been enrolled in any preschool?                                                 NO

If yes, Name of daycare                                                         Dates of Enrollment                                                            

Parent/Guardian signature:                                                                                     Date:                                     

Director Signature:                                                                                                   Date:                                     

Child’s Name:                                                         DOB:         /      /                         Date:         /      /            

Infant Feeding Schedule

  1. Food/Bottles Brought daily (quantity):
  2. Instructions for Feeding:                                                                                                                                                                                    
  3. I plan to nurse:(approximate time)

Changes in Schedule (must be recorded as eating habits change)

 

Food:            Date to Introduce:                        New instructions               Parent/staff Signature:

Milk                                                                                                                                                  

Baby Food                                                                                                                                    

Juice                                                                                                                                                

Cereal                                                                                                                                              

Table Food                                                                                                                                    

*Must be completed for all children less than 15 months old

*******************************************************************************************************Permission to administer topical Ointment/Powder

Authorization must be provided for staff to apply over the counter, topical ointments, topical teething ointment or gel, insect repellents, lotions, creams, and powders, such as sunscreen, diapering  creams, baby lotion, and baby powder.

Item must be provided in its original container and labeled clearly with the child’s name. Staff will keep items out of reach of children when not in use.

Child’s Name____________________________________________________            __________

Name of Ointment:                                                     From January 2017   to December 2017


Apply to:                                                                                         When to apply:

¨    All exposed skin                                                               Before going outside in the afternoon

¨   Diaper area                                                                             After each diaper change

¨   Other            _________                                                                   After a bowel movement

                                                                                                                        Other:                                  

                                                                                                                      Amount:__________                                                                                          ( we can’t accept as needed)


I give permission to my child care provider to apply the medication listed above as instructed.

Parent Signature:                                                             Date:                                    

 

Immanuel Baptist Daycare Child Profile

 

 

We would like to provide our staff with a better understanding of your child. Please take the time to fill out the information below so we may better meet your child’s individual needs.

 

Name of Child                                                                               Date           /        / DOB         /        /        

Does your child have any known Allergies?             Yes     N o      Is your child under doctor’s care?                  Yes     No      

Is your child on any continuous medication? Yes     No       Any operations or hospitalizations? Yes     No

Any history of diseases/recurrent illness?              Yes     No       Diabetes?                                           Yes            No

Convulsions?                                                  Yes     No       Heart trouble?                                                Yes            No

Others what/when?                                       Yes     No       If yes explain                                                             

Any physical disabilities?                                         Yes     No       If yes explain                                                             

Does your child have siblings?                                                                                                                         

What is your child’s favorite toy?                                                                                                                                

Does your child have a special blanket or special interests?                                                                              

What type of foods does your child eat?                                                                                                                  

Dislikes?                                                                                                                                                                 

Does your child have any fears?                                                                                                                                   How would you describe your child’s personality?                                                                                                 

Specific needs/Comments?                                                                                                                            

Name Parent/Guardian                                                              Address                                                      

City                                       State                        Zip                 Signature of parent                                                         

*******************************************************************************************************

Child’s Medical Report

This examination must be completed and signed by a licensed physician, his authorized agent current approved by NC Board of Examiners, a certified nurse practitioner, or a public health nurse meeting the DEHNR standards for EPSDT program.

 

Child’s Name___________________________________________________________________

Height %                  Weight %                  Head             Eyes             Ears                          Nose            

Heart                                    Chest                        Abd/GU                Ext                Neurological System                    

Skin              Should activities be limited yes                        No                            

Results of Tuberculin test, if given Type                 Date              Normal                      Abnormal                       

Any other recommendations:                                                                                                                            

Signature of authorized examiner/title                                                                                  Date                         

Phone Number                                           

Immanuel Baptist Church Daycare 2015 Tuition Rates

 

Full-time                                                                                     Daily (Drop-In) Rate

Infants                                               $145.00 week                      $40.00

Toddlers                              $145.00 week                                 $40.00

Two’s                                                $135.00 week                                  $40.00

Three’s                                 $135.00 week                                  $40.00

Four’s                                                $135.00 week                                  $40.00

 

5% Discount if you pay one month in advance. There is also a 5% discount if you have more than one child. ONLY one 5% discount per family.

10% Discount for Immanuel Baptist Church Member children.

*Drop in care is only offered when space is available.

 

Before/ After School                                                                     After Care Only

5 Days                $70.00                                                           5 Days                      $50.00

3 Days                $50.00                                                           3  Days                     $40.00

 

            Before Care Only (full week option only)                                                                $25.00

            All Day Care (teacher & snow days if child is enrolled)                                       $14.00 (add’l)

            All Day Care (drop in rate)                                                                                           $40.00

            Full Week of Care (Summer & Winter breaks)                                                        $135.00

*Drop in care is only offered when space is available.

5% Discount isn’t available for Before &After School Care and Drop In Rates.

 

Additional Fees

Annual Yearly Fee (non-refundable)                                                              $35.00

                                                      Second child                                                                      $15.00

Registration Fee (non-refundable)                                                                              $60.00

                                                      Second Child                                                        $30.00

Summer Registration (nonrefundable)                                                                        $100.00

Teacher Discount Registration (nonrefundable)                                                   $100.00

 

Returned Check Fee $25.00

We accept cash, check, money order, Visa, MasterCard, American Express, & Discover.

No credit is allowed for holidays, inclement weather, or other required closings, or child absences.

 

Fees are subject to change with two weeks’ notice to all parents