Lil’ Bloomers Daycare Center
Enrollment/Registration Form
Child’s Name_____________________________ Sex _______
Date of Birth______________ Nickname _________________
For Office Use Only- Identity verification
Place of Birth: ____________ Birth Date: _______________
Birth certificate Number: ___________________ Date issued: _____________
Other Form of Proof: _________________________________________________________________________________
Mother/Father/Guardian Information
List only individuals who have legal custody of child. If mother is not listed or if guardian is not a parent, legal proof of custody must be provided)
Name_______________________________________ SSN________________________
Address _________________________________________________________________
City___________________________ State _______________ Zip _______________
Home Phone _____________ Cell Phone ______________ Work Phone _____________
Employer ___________________________ Email Address________________________
Employer Address_________________________________________________________
Mother/Father/Guardian Information
(List only individuals who have legal custody of child. If mother is not listed or if guardian is not a parent, legal proof of custody must be provided)
Name_______________________________________ SSN________________________
Address _________________________________________________________________
City___________________________ State _______________ Zip _______________
Home Phone _____________ Cell Phone ______________ Work Phone _____________
Employer ___________________________ Email Address________________________
Emergency Contact Information
Persons authorized to pick-up the child daily: _________________________________
_______________________________________________________________________
*Persons unauthorized to pick-up the child daily: ______________________________
Persons contacted in case of illness, accident or emergency and authorized to pick-up the child from the school if the parents or guardians cannot be reached. (Need at least 2)
Name ______________________________________ Phone _______________________
Address ____________________________________ Relationship __________________
Name ______________________________________ Phone _______________________
Address _____________________________________Relationship _________________
Child’s Physician _____________________________ Phone ______________________
Child’s Dentist _______________________________ Phone ______________________
Authorization for Emergency Medical Care
(Please note authorization must be NOTARIZED)
If I cannot be contacted in an emergency situation, I authorize the center’s staff to obtain emergency medical treatment for my child.
Signature of Parent or Guardian _____________________ Date _________________
Subscribed and Sworn to before me this _______ day of _______________________
Family
Mother’s Occupation ___________________ Father’s Occupation _________________
Other family members (brothers, sisters, grandparents, etc.) living at home.
Name Age Relationship
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Health
What communicable diseases had the child had?
Measles (Big Red) ______ Measles (3 day) _______ Mumps _______
Chicken Pox _____ Whooping Cough ______ Other ____________________________
Any chronic physical problem? _____________________________________________
*Type of accommodations needed: __________________________________________
*if special accommodations are needed a current copy of the child’s IEP or ISP is required
Medications
Are there any medications given on a regular basis? (Please list medications and reasons): _______________________________________________________________
Brand of Infant Formula (if applicable): ______________________________________
Please note: It is Lil’ Bloomers policy to feed infants on a demand basis unless other written permission
from the child’s physician is provided.
Speech
Describe you child’s speech: Rapid: ____ Slow ____ Moderate ____ Clear ____
Talks Constantly _____ Seldom Speaks _____ Uses Many Words ____
Uses Few Words _____
Toileting
Does your child have any special toileting needs? ___ if so please explain _____________________________________________________________________
Sleep Patterns
What time does your child go to sleep at night? _______ Awaken? _______
Does he/she walk, talk or cry out at night? ____________________________________
Does he/she take anything to bed with them? __________________________________
Does he/she take naps? ______ Typical time of nap and duration? _________________
Schooling/Child Care
Please list any previous schools/ and or child care center enrollment:
______________________________________________________________________
Name of school/center City/Town State Date
______________________________________________________________________
Name of school/center City/Town State Date
Is your child attending another school/center along with our center? _______________
Name of school/center____________________________________________________
Interests
Has he/she had experience playing with other children? _________________________
With what age child does he/she prefer to play? _______________________________
What are his/her favorite activities at home? __________________________________
Does he/she like to: Be Read To: ____ Listen to music? _____ Play Outdoors? ______
Can he/she ride a tricycle? _____
Has he/she had experience with: Clay? _____ Scissors? _____ Easel Painting? _____
Blocks? ____ Puzzles? _____ Finger Painting? _____
Enrollment Days/Times Sheet
My child _______________________________________________ will be attending Lil’ Bloomers on the following days and times each week:*
Monday _________ to _________
Tuesday ________ to _________
Wednesday _________ to _________
Thursday _________ to _________
Friday _________ to _________
*We ask parents to list the estimated and typical drop off and pick up
times for teacher reference and activity planning. Please understand if a child is enrolled for a full-day he/she can attend anytime from 6 a.m. until 6 p.m. on the designated above enrollment
days.
*I understand that I must give at least a two weeks notice before changes can be made to the above enrollment days. Changes from part-time to full-time enrollment, or full-time to part-time enrollment, can only be made if availability allows and at the directors discretion.
_________________________________ ______________________
Parent’s Signature Date
Lil’ Bloomers Tuition Rates
Lil’ Bloomers tuition rates starting January 4, 2016 are as follows:
Infants (birth-15 months)
$166.00 weekly for full- time/full-day (Monday-Friday)
$38.00/ per day- part-time/full- day (2 or 3 days a week)
Toddlers (16-23 months)
$157.00 weekly for full- time/full-day (Monday-Friday)
$36.00/ per day- part-time/full- day (2 or 3 days a week)
2 Years
$140.00 weekly for full- time/full-day (Monday-Friday)
$32.00/per day- part-time, full-day rate (2 or 3 days a week)
3 Years
$132.00 weekly for full- time/full-day (Monday-Friday)
$29.00/per day- part-time, full- day rate (2 or 3 days a week)
4-5 Years
$125.00 weekly for full- time/full-day (Monday-Friday)
$27.00/per day- part-time, full- day rate (2 or 3 days a week)
5-10 Years (in Kindergarten or higher grade)
$110.00 weekly for full- time/full-day rate
$25.00/per day for part-time, full- day rate (2 or 3 days a week)
Registration Fee: $50.00 (non-refundable, due upon enrollment)
Activity Fee: $35.00 (charged every fall)
Return Check fee-$30 per incident
Late Payment Fee-$10.00 per incident
Late pick up Fee-$1.00 per minute per child after 6:00 p.m.
*10% discount on multiple family enrollments
Financial Agreement
I ______________________________________________ (please print name),
the parent of _________________________________agree to pay my child’s daycare tuition in the amount of ________ each day/week (circle).
I understand my payment is due on the first working day of each week or payment is due the first day of the week my child attends Lil’ Bloomers for that current week. If I have not paid by Wednesday of the current week (full-time children), or the second working day my child attends (part-time children), I will be charged a late fee of $10.00. I also understand that if I do not pick up my child by the center’s closing time, I will incur a charge of $1.00 per minute per child. In the event that my child’s tuition account becomes two weeks past due, I understand my daycare services with Lil’ Bloomers will be terminated. I also agree to pay all costs and expenses including, but not limited to, court costs and attorney fees that may be incurred by Lil’ Bloomers, in connection with the collection of tuition and the enforcement of this agreement.
_____________________________________________ _________________
Parent/Guardian Signature Date
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Dear Lil’ Bloomers Parents:
The staff members of Lil’ Bloomers Daycare along with local advertising (newspapers, magazine, etc) companies may take pictures of our daycare and the children, throughout the year. By taking pictures this will help our center with advertisement and with the opportunity for parents to take a look at all the different types of activities the children are involved in throughout the year. When taking pictures for advertisement in newspapers and magazines, the children’s names will never be used or listed.
Thank you,
Lil’ Bloomers Daycare Staff
Please fill out this form stating whether your child is or is not allowed to be photographed.
(Circle One) I hereby give I do not give
Permission for Lil’ Bloomers’ Staff and/or local newspapers/magazine companies to photograph my child, ________________________________________, while at daycare. (List child’s full name)
I understand these pictures are for fun and will be taken in a positive manner. I also understand my child’s name will not be listed when pictures are used in the newspapers or magazines.
___________________________ _______________
Parent’s Signature Date
Lil’ Bloomers Daycare Policy Agreement Form
1. I understand that I am not allowed to leave my child unsupervised at Lil’ Bloomers. I must walk my child into Lil Bloomers each morning, sign my child in and release my child to a Lil’ Bloomers staff member before leaving.
2. I understand Lil’ Bloomers must have all required forms and documentation fully completed and on file prior to my child attending Lil’ Bloomers Daycare.
3. I understand that Lil’ Bloomers will not release my child to anyone except parents/guardians without written permission. I understand that Lil Bloomers will release my child to either parent unless a court order indicating sole custody is provided and on file at the center. I understand I must give Lil’ Bloomers a list of those persons authorized, and unauthorized to pick up my child.
4. I agree to support and reinforce Lil’ Bloomers daycare policies and procedures that are stated in the parent handbook.
5. I understand the director or a Lil’ Bloomers staff member will notify me whenever my child becomes ill and I agree to pick up my child or send an authorized person, to pick up my child, within one hour of receiving notice.
6. I understand my child cannot attend Lil Bloomers daycare if he/she has an illness that is contagious or threatens the health of the other children. I understand the Health Department regulations concerning periods of infection will be enforced. I understand that my child must be fever- free for at least 24 hours before returning back. I also understand prescription medication must be administered at least 24 hours before he/she can return to daycare.
7. I understand I am required to inform the center, within 24 hours or the next business day, if my child (or any other member of the immediate family/household) has developed a reportable communicable disease, as defined by the State Board of Health. Life threatening diseases must be reported immediately!
8. I authorize Lil’ Bloomers Daycare to obtain immediate medical care if an emergency occurs and the parent(s)/guardian(s) cannot be located immediately**
9. I understand my daycare services with Lil’ Bloomers may be terminated for any of the following reasons:
· My child’s tuition account becomes more than two weeks past due.
· Failure to respond in a timely manner, when contacted by the center to pick up my child when he/she is sick.
· Failure to obey the “24 hour illness recuperation period.”
· Failure to provide the center with up-to-date emergency contact information and health immunization records.
· My child’s behavior patterns threaten the health or safety of themselves, other children or staff members of the center.
If parental/guardian or family support is not received when a child is found to have a behavioral or learning problem.
· Parent or guardian becomes uncooperative with Lil’ Bloomers’ program philosophy, and its procedures and policies, thus, showing negative actions toward the daycare center.
· Parents, who are continuously late in picking up their child from Lil’ Bloomers, will be asked to make other daycare arrangements.
I have read all the Policies listed above, and I have read and fully understand all Policies and Procedures in the Lil’ Bloomers Daycare Parent Handbook.
Mother/Guardian Signature______________________________ Date______________
Father/Guardian Signature _______________________________ Date______________
Director’s Signature _______________________________ Date______________
**If there is an objection to seeking emergency medical care, a statement should be obtained from the parent(s) or guardian(s) stating the objection(s) and the reason for the objection(s).




38 Bloomer Springs Road
McGaheysville, VA 22840
(540) 289-5533
Email: lilbloomersdaycare@eabreeden.com
Enrollment date: ___________
Withdrawal date: ___________
Lil' Bloomers Daycare
Love, Learning & Laughter