Expressive Imagination Academy Enrollment Packet · Expressive Imagination Academy, LLC 1901 South 12th Street, Bldg. 1, Suite 8, Allentown, PA 18103 Ph: 610-841-9997 Fax: 610-841-9697

Expressive Imagination Academy, LLC 1901 South 12th Street, Bldg. 1, Suite 8, Allentown, PA 18103 Ph: 610-841-9997 Fax: 610-841-9697

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Expressive Imagination

Academy

Enrollment Packet

REVISED 04/2016


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Registration Information

Registration Date:

Child Information

First Name: M.I. Last Name:

Name child prefers to be called: Grade/Class:

Child’s Address:

Gender: [ ] Male [ ] Female Date of Birth: ______________

Photographs: May we take and maintain a photo of your child for security purposes? [ ] Yes [ ] No

Parent/Guardian Information

Mother/Guardian First Name: M.I. Last Name:

Address:

Occupation: Home Phone: ( )

Employed By: Office Phone: ( )

Work Address: Work Hours: Cell Phone: ( )

[ ] Custodial Parent (If married, mark both parents) Email:

Driver’s License #:

Marital Status: [ ] Married [ ] Single [ ] Divorced [ ] Separated [ ] Widowed

[ ] Other_____________________

Father/Guardian First Name: M.I. Last Name:

Address:

Occupation: Home Phone: ( )

Employed By: Office Phone: ( )

Work Address: Work Hours: Cell Phone: ( )

[ ] Custodial Parent (If married, mark both parents) Email:

Driver’s License #:

__ __

Marital Status: [ ] Married [ ] Single [ ] Divorced [ ] Separated [ ] Widowed

[ ] Other_____________________


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Emergency Contacts & Authorized Pickup Persons:

1st Contact/Pick Up

Name: ___________________________________________

Phone: ________________

Relationship to the Child: __________________________

2nd Contact/Pick Up

Name: ___________________________________________

Phone: ________________


3rd Contact/Pick Up

Name: ___________________________________________

Phone: ________________


4th Contact/Pick Up

Name: ___________________________________________

Phone: ________________



4

Medical Information

Physician / Health Care Provider Name:

Phone: ( )

Address:

Insurance Provider (Required):

Policy Number (Required):

List any existing medical conditions, medication your child may require:

1.) __________________________________________________________________________

2.)

3.)

4.) __________________________________________________________________________

**ALL MEDICATIONS MUST BE GIVEN WITH PRESCRIBED LABELS FROM HEALTH CARE PROVIDER, WITH

SPECIFIC WRITTEN CONSENT FOR TIME AND ADMINISTRATION.

Allergies (Including Food/Medication):

Special Disabilities (if any): ____________________________________________________

_____________________________________________________________________________

Medical or Dietary Information in an Emergency Situation: _________________________

_____________________________________________________________________________

Additional Special Needs Information: ___________________________________________

_____________________________________________________________________________


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Parental Permissions

Parent’s Signature is Required for Each Item Below to Indicate Parental Consent

Obtaining Emergency Medical Care: ______________________________________________

Admin of Minor First Aid Procedures: _____________________________________________

Walks and Trips: ______________________________________________________________

Swimming: __________________________________________________________________

Transportation by Facility: ______________________________________________________

Wading: _____________________________________________________________________

Permission to Photograph Child I give Expressive Imagination Academy, LLC, permission to photograph my child/children

for the following purposes:

* Still Photographs

* Display in facilities scrapbook or bulletin boards shown to current or prospective

clients

** Display still photos on my daycare website

** Only first names and possibly last initials (In the event of two or more children with

the same first name) will be displayed on the facility website.

I understand that it is my responsibility to update this form in the event that I no longer wish

to authorize one or more of the above uses. I agree that this form will remain in effect during

the term of my child’s enrollment.

____________________________________ ____________________________________

Parent/Guardian Signature Date

I am declining to have my child photographed.

____________________________________ ____________________________________



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PAYMENT AGREEMENT

Child Name: ____________________________________________

Tuition Payment Amount: $__________ Arrival time: _____ Pick-Up time: _____

All Payments are due on Monday (or your child’s first day of care) in full.

Please circle one: Part-Time Full-Time Before / After Care Full-time: Childcare that is provided 25 hours or more per week

Part-time: Childcare that is provided less than 25 hours per week

Please circle the days required for child care:

MON TUES WED THURS FRI SAT SUN

*All meals (including formula/baby food) are provided by Expressive Imagination Academy.

**Two changes of clothing including undergarments must be bought in. Bedding should be brought in on the first

day of care each week and taken home at the end of the week. Blankets, sheets, and or sleeping bags must be

supplied by parent or guardian.

***For Infants and Young Toddlers, parents must supply diapers

Meal times are as follows:

Breakfast: 7:15am – 8:15am Lunch: 11:00am-12:00pm Dinner: 5:00pm-6:00pm

Allergies: __________________________ ___________________________

Person(s) Designated By Parent to Whom Child May be Released

1.)

2.)

3.)

4.)

____________________________________ ____________________________________


____________________________________ ____________________________________

Director / Owner Signature Date

Date of Admission Date of Withdrawal

Periodic Review

Parent / Guardian Signature: Date:


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FEES / POLICIES Late Fee’s

There is a ten hour maximum (per day) that your child may be left in care. There is a fee of

$15.00 for every half-hour (30 minutes) a child is picked up after their indicated pick-up time.

Any accrued late fees will be added to your payment the following week.

All emergency contacts are listed on Emergency Consent form. I agree to keep their names

and numbers as well as my own updated as needed.

Sick care:

Children are not to be brought or left in care with the following symptoms:

Excessive Runny Noses Excessive coughing Diarrhea Sneezing Temperature 101+

(Other illness/symptoms are listed in Parent Handbook)

As this is contagious and a sign of infection, your child must remain out of care a full 24 hours

and will require a written note from a licensed health care professional stating that the child is

not contagious in order to return. Expressive Imagination Academy does not have the ability

to take care of sick children along with other children who are non-symptomatic. Therefore,

please do not bring your ill child as you will be called and required to pick them up.

Children on medication must bring instructions from the doctor, or a form will be provided to

the parent to list permission, dosage, and times medicine is to be administered. Immunization

records and the date of your child’s last physical examination must be kept up to date. Parents

are required to review and update the records for accuracy at least once in a six month period.

Please notify us of any health problems or concerns regarding your child or family.

[ ] I have received a copy of the Expressive Imagination Academy Parent Handbook

____________________________________ ____________________________________


____________________________________ ____________________________________

Director / Owner Signature Date


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“Getting To Know You”

Child’s Name: ___________________________________________

Name of Meeting Attendees: _____________________________________________________

Meeting Dates: Enrollment: ______________ Getting To Know You: _______________

If “Getting To Know You” meeting was refused...

Date of refusal by parent: _____________ Parent Initials: _________

1. Who lives in the household with your child: (Please list names, relationship & age)

_____________________________________________________________________________

_____________________________________________________________________________

2. Does your child have any parent that does not live in the home? Yes ___ No ___

Does your child visit this parent? Yes ____ No ____ Are there any custody issues we should

discuss? Yes ____ No ____

_____________________________________________________________________________

_____________________________________________________________________________

3. Does your child respond to nicknames? __________________________________________

4. Is there any information about your family that you would like to share?

_____________________________________________________________________________

_____________________________________________________________________________

5. Has your child been in an early learning program or child care before? If yes please answer

the following:

Where: __________________________________ When: ____________________________

How Long: ___________ Reason for leaving: _______________________________________


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6. What are your child’s favorite foods? ____________________________________________

_____________________________________________________________________________

7. What are your child’s least favorite foods? _______________________________________

_____________________________________________________________________________

8. What (how do you) calms your child down? ______________________________________

_____________________________________________________________________________

9. What angers your child? ______________________________________________________

_____________________________________________________________________________

10. Are there any special problems or fears we should know about? _____________________

_____________________________________________________________________________

11. Does your child have any special needs / medical, developmental, social or mental health?

Yes ___ No ____ Do any of these special needs require special care by our teachers/staff?

_____________________________________________________________________________

_____________________________________________________________________________

12. Is your child potty trained? Yes ____ No ____ Would you like our assistance? Yes ____

No ____

13. Is there any information that will help us make the first few days in our program easier for

your child?

_____________________________________________________________________________

_____________________________________________________________________________


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Stakeholders List / Parent Input

1. What school district will your child be attending in the future?

____________________________________________________________________

____________________________________________________________________

2. Please write the appropriate Elementary/ Middle School your child attends or will be

attending.

____________________________________________________________________

____________________________________________________________________

3. Please share any other possible partner of human service agency that would be

responsible for the success of the transition to kindergarten for your child.

____________________________________________________________________

____________________________________________________________________


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IEP / IFSP

The status of your child’s growth and development is based on developmental assessments. If

your child currently has an IEP / IFSP it would be beneficial if you would share a copy of this

plan with us, so that we can work together to ensure the guidelines are practiced.

1. Does your child have an IEP: Individualized Education Plan or IFSP Individualized

Family Service Plan? Yes ____ No ____

If so, we would like a copy of the plan so that we can provide the best possible learning

experience for your child.

2. What program or individuals work with your child in regards to these special needs?

Would you sign a release of information with them so they can speak with us about how

to provide enhanced support for your child?

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

[ ] My child does not have an IEP / IFSP

____________________________________ ____________________________________


[ ] My child has an IEP / IFSP plan, which I have provided to EIA

____________________________________ ____________________________________


[ ] My child has an IEP / IFSP that I choose not to provide at this time.

____________________________________ ____________________________________


CHILD HEALTH REPORT (55 PA CODE §§3270.131, 3280.131 AND 3290.131)

Par

ent/P

rovi

der

fill i

n th

is p

art. CHILD’S NAME: (LAST) (FIRST) PARENT/GUARDIAN:

DATE OF BIRTH: HOME PHONE: ADDRESS:

CHILD CARE FACILITY NAME:

FACILITY PHONE: COUNTY: WORK PHONE:

� I authorize the child care staff and my child’s health professional to communicate directly if needed to clarify information on this form about my child.

PARENT’S SIGNATURE:

Par

ents

may

wri

te im

mun

izat

ion

date

s; h

ealth

pro

fess

iona

l sho

uld

veri

fy a

nd c

ompl

ete

all d

ata.

DO NOT OMIT ANY INFORMATION This form may be updated by a health professional. Initial and date any new data. The child care facility needs a copy of the form.

HEALTH HISTORY AND MEDICAL INFORMATION PERTINENT TO ROUTINE CHILD CARE AND DIAGNOSIS/TREATMENT IN EMERGENCY (DESCRIBE, IF ANY): � NONE

DESCRIBE ALL MEDICATION AND ANY SPECIAL DIET THE CHILD RECEIVES AND THE REASON FOR MEDICATION AND SPECIAL DIET. ALL MEDICATIONS A CHILD RECEIVES SHOULD BE DOCUMENTED IN THE EVENT THE CHILD REQUIRES EMERGENCY MEDICAL CARE. ATTACH ADDITIONAL SHEETS IF NECESSARY. � NONE

CHILD’S ALLERGIES (DESCRIBE, IF ANY): � NONE

LIST ANY HEALTH PROBLEMS OR SPECIAL NEEDS AND RECOMMENDED TREATMENT/SERVICES. ATTACH ADDITIONAL SHEETS IF NECESSARY TO DESCRIBE THE PLAN FOR CARE THAT SHOULD BE FOLLOWED FOR THE CHILD, INCLUDING INDICATION OF SPECIAL TRAINING REQUIRED FOR STAFF, EQUIPMENT AND PROVISION FOR EMERGENCIES. � NONE

IN YOUR ASSESSMENT, IS THE CHILD ABLE TO PARTICIPATE IN CHILD CARE AND DOES THE CHILD APPEAR TO BE FREE FROM CONTAGIOUS OR COMMUNICABLE DISEASES? � YES � NO IF NO, PLEASE EXPLAIN YOUR ANSWER:

HAS THE CHILD RECEIVED ALL AGE APPROPRIATE SCREENINGS LISTED IN THE ROUTINE PREVENTIVE HEALTH CARE SERVICES CURRENTLY RECOMMENDED BY THE AMERICAN ACADEMY OF PEDIATRICS? (SEE SCHEDULE AT WWW.AAP.ORG)

� YES � NO

NOTE BELOW IF THE RESULTS OF VISION, HEARING OR LEAD SCREENINGS WERE ABNORMAL. IF THE SCREENING WAS ABNORMAL, PROVIDE THE DATE THE SCREENING WAS COMPLETED AND INFORMATION ABOUT REFERRALS, IMPLICATIONS OR ACTIONS RECOMMENDED FOR THE CHILD CARE FACILITY.

VISION (subjective until age 3)

HEARING (subjective until age 4)

LEAD

RECORD DATES OF IMMUNIZATIONS BELOW OR ATTACH A PHOTOCOPY OF THE CHILD’S IMMUNIZATION RECORD

IMMUNIZATIONS DATE DATE DATE DATE DATE COMMENTS

HEP-B

ROTAVIRUS

DTAP/DTP/TD

HIB

PNEUMOCOCCAL

POLIO

INFLUENZA

MMR

VARICELLA

HEP-A

MENINGOCOCCAL

OTHER

MEDICAL CARE PROVIDER:

ADDRESS:

PHONE:

SIGNATURE OF PHYSICIAN, CRNP OR PHYSICIAN’S ASSISTANT

TITLE:

LICENSE NUMBER: DATE FORM SIGNED:

CD 51 09/08

Documents

Expressive Imagination Academy Enrollment Packet · Expressive Imagination Academy, LLC 1901 South 12th Street, Bldg. 1, Suite 8, Allentown, PA 18103 Ph: 610-841-9997 Fax: 610-841-9697