First Day Checklist · ☐ My child is enrolled _____ Program (OCS, CITC, P1, P2, other). I understand that it is my responsibility to provide a current authorization as needed. I

NORTHERNLIGHTSPRESCHOOLANDCHILDCAREPhone:(907)274-2040Fax(907)277-3470E-mail:[email protected]#200AnchorageAK99503(www.nlpkak.com)

HoursofOperation:M-F6:30a.m.-7:30p.m. 1

FirstDayChecklist

Child’sConfidentialFile*Allpaperworkmustbecurrentatthetimeofenrollmentandkeptcurrentasneeded

✔

ImmunizationRecord

AnnualPhysicalExam

Emergencycard

RegistrationForm

Parentsign-off

DayCareAssistantContract(notneededifselfpay)

Orientation

RequiredChildren’sApparelanditems*Pleaselabelallpersonalbelongingswithpermanentmarker

NLPS&CCisnotresponsibleforanylostitems

✔

Indoorshoes(sneakers)

Outdoorshoes(sneakersforsummerandsnowbootsforwinter)

Blanketandchildsizepillow(shouldfitincubby)

Onepairofextraclothes(top,bottom,underwear,socks)

InfantandToddler(Inadditiontotheaboveitems)

✔

Diaperandwetwipes(centercharges$2.00/diaperandwetwipe)

Lotion,babypowder,etc.(musthaveformsignedatfrontoffice)

Twopairsofextraclothes



RegistrationForm

StartDate://20

SectionI:Child’sInformation

Name(firstandlast): Age:

DOB: Placeofbirth: Gender:☐Male☐Female

Address: SS#:

City: State: Zip: Primary/2ndLanguage:

Phone#

PreviousChildcarefacility:

SectionII:FamilyInformation

Father/GuardianName:

Employer: SS#:

Position: Work#: DL#:

Mobile#: Home#:

Mother/GuardianName:

Employer: SS#:

Position: Work#: DL#:

Mobile#: Home#:

EmergencyContactName:

Phone#: Relationship:



BillingAgreementFull-timeorPart-timeschedule

Mychildwillbeenrolled(pleasecheckone):

☐Full-time(5-10hours)�Part-timeMorning(6:30AM-12:00PM)�Part-timeAfternoon(2:00-7:30PM)

☐Iunderstandthatbyenrollingmychildforpart-time,itmeansthatmychildwillnotattendthecenterfor

morethan5hoursaday.However,ifthetimemychildisatthecenterexceeds5hoursperdayIwillbe

chargedforthefulltimerate.

Approximatetimeofarrival:A.M.Approximatetimeofdeparture:P.M.

DaysinAttendance(pleasecircle):MTWTHF

MonthlyStudentEnrollment

☐ Mychildisenrolledonamonthlyratewhichcosts$________.Iunderstandthatthisamountmustbepaid

priortooronthe5thbusinessdayofthemonthorIwillcompleteafinancialagreementform.Ifurther

understandthatadditionalchargeswillbeaddedforextraforhoursthatwerenotindicatedonthisagreement

orthatexceedsthecenterhours.

DailyStudentEnrollment

☐ Iunderstandthatmycostwillbe$__________perdayandIwillbebilledevenifmychildisnotin

attendanceonthesedaysthatIhaveindicatedabove.Iagreethatmychildwillnotattendthecenterfordays

andhoursthatarenotindicatedonthissheet.Ifchangesaremadeinmychild’sdailyscheduleIwillnotifythe

administration.IunderstandthatifcareisneededforadditionaldaysImustchecktoseeifaslotisavailable

andwillbechargedforthatdayinadditiontothescheduleddays.Mychildisallowedtobescheduledforfive

daysoftheweek(M-F).Saturdayisaseparatecareandattendance/billingprocess(formoreinformationon

Saturdaycarepleasetalktothefrontoffice).

ChildCareAssistance/DCA/JOBS…etc

☐ Mychildisenrolled_______________Program(OCS,CITC,P1,P2,other).Iunderstandthatitismy

responsibilitytoprovideacurrentauthorizationasneeded.IalsounderstandthatIneedtocheckatthe

beginningofeachmonthtomakesurethecenterhasmymostcurrentauthorization/childcareassistance

form.Ifurtherunderstandthatitismyresponsibilitytopayadditionalchargesthatarenotfundedbymy

childcareassistancepriortoorbythe5thbusinessdayofthemonth.Contractsaredueonthefirstofmonthif

youareonasubsidedprogramthefamilyisresponsibleforprocessingalldocumentation.



BillingAgreementEffectiveJanuary1,2018

Infant/Toddler Full-time Part-time (FT/PT)DropIn

5Day 850 600 60/50

4Day 750 550 60/50

3Day 650 500 60/50

PreschoolAge Full-time Part-time (FT/PT)DropIn

5Day 700 560 50/40

4Day 600 500 50/40

3Day 500 450 50/40

SchoolAge Full-time Part-time(AM/PM) (FT/PT)DropIn

5Day 745 550summer/420/375a/400p 50/40

4Day 645 500summer/420/365a/375p 50/40

3Day 545 450summer/420/355a/365p 50/40

Toddler:15-35monthsPreschoolage:36mo.-4yearsSchoolage:5-12years

OtherFees

RegistrationFeeof$75.00/childannuallyisdueeverySeptember.LatePickupFeeis$2/minuteperchildoverthe10-hourlimit.Additional$200permonthifover10hourcareisnecessary.LateTuitionFee$50willbechargedafterthe5thdayandafterthe20tha$100latefeewillbeapplied.NSFFeeforreturnedchecksis$25andallNSFchecksandfeestobepaidincash.

Drop-in/Drop-offtimeinformation

Drop-instudentsmustcallpriortoarrival(preferablyminimum1daybefore-hand)tocheckforspaceavailability.Nochildrencanbedroppedoffbetween10AM–2PM

WithdrawalTwoweekswrittennoticeisrequiredforwithdrawalofyourchildfromourprogram.Fromthedateofreceivingsuchnotice,ourcenterwillchargetuitionfeesuptothedateofwithdrawal.Alltuitionsarenon-refundable.Ifchildhasbeenabsentoverfivedayswithoutnoticechildwillberemovedfromourattendancelist.Parent/GuardianSignature: Date:



MedicalForm

SectionIII:MedicationInformation

Allergies ReactiontoAllergy ReliefMedication

Othertypesofmedicationandreasonforuse:

Otherhealthconcerns:

☐Ifextensiveallergylistisrequiredpleaseprovideadoctor’snote.Ifyourchildrequiresmedication,amedicationformmustbefilledoutatthefrontofficeandmedicationmustbe

droppedoffatthefrontdesktobeadministeredtochildrenwithdetailedinstructionslistedin

themedicalform.

Parent/GuardianPrintedName:

Parent/GuardianSignature Date:



PermissionSlipforPictures

☐IgivepermissionforNorthernLightsPreschooltotakepicturesofmychildduringnormal

classroomsittings,formalpictureday,artworkpostedontheNLPSwebsiteandfor

yearbook(ifapplicable)

Child’sName:


Parent/GuardianSignature: Date:

�IgivepermissionforNorthernLightsPreschooltotakepicturesofmychildduringformal

picturedayonly

Child’sName:



☐Idonotwantmychild’spicturetakenorsharedonNLPS&CCwebsiteortakenduring

formalpicturedayevents

Child’sName:



ChildPhysicalExaminationForm



PhysicalExaminationrequiredbyMunicipalOrdinance16.55.090Children’sCareCenterStudentName: DOB:School:Parent/GuardianName:Address:Homephone#:Dateofphysicalexamination:// Parentpresentatexamination:�Y�N

AssessmentEyes: Height:Ears: Weight:Noseandthroat: Vision:Mouth: Medication:Teeth:Lymphnode:Heart:Lungs:Abdomen:Genitals:Orthopedic:Nervoussystem:Skin:Nutrition:Endocrine:Other/positivefindings:

Abletoparticipateinusualgroupactivities?�Y�NProvider’sSignature Date:

*Physician’sOfficestamp(required)

Parent/GuardianSignOff



ParentPolicyHandbookAgreementForm�IhavereadandreceivedacopyoftheNorthernLightsPreschoolandChildcareParent

PolicyHandbook.IagreetothetermsandpoliciesoftheNorthernLightsPreschooland

ChildcareParentPolicyHandbookandbillingprocedures.

Child’sName:



LateFeesandReimbursement

LateFeeAgreementForm

☐Tuitionspastthe5thbusinessdayofthemontharesubjecttoalatefee.Returned

checksaresubjecttoa$25latefeeaswell.Wewilldeducta2%servicechargeontuition

refundifthepaymentwasmadethrucreditcard.Childrenleftpast7:30pmarecharged

2.00dollarsperminuteandmustbepaidbythenextbusinessday.

ReimbursementAgreementForm

☐ Alltuitionisnon-refundableunlessintheeventofanincorrectbillingerrortheincorrectchargemaybereimbursed.Intheeventthataparent/guardianonachildcareassistance

programdoesnothavethecurrentmonthlycontracttheyarerequiredtopaythechild’s

monthlytuitionandwillbereimbursedinfullafterthecontracthasbeenreceived.

Child’sName:


SchoolHours



Ourschoolisopenfrom6:30am-7:30pmMondaythroughFriday.Ifyoupickyour

child/childrenupafter7:30pmyouwillbecharged$2perminuteperchildeveryminuteyou

arelate.Similarfeesapplytochildrenexceedinga10-hourlimitfortheday.Ifyouneed

extrahoursa$200feeappliesamonth

Evenifyouhavearrangedforsomeoneelsetopickupyourchildandtheyarelate,youas

theparent/guardianareresponsibletopayforthislatefee.Thelatefeemustbepaidin

cashbyorbeforethecloseofthenextday,andifnot,yourchildwillnotbeabletoattend

untilthebalanceisfullypaid.

Ifyouhavequestionspleasefeelfreetoaskatthefrontoffice.

� Iunderstandthatitismydutytopickupmychild/childrenontime.Alllatefeesaremy

responsibilitytopay.


NLPCCDATESOFCLOSURE:



HolidayClosures

Date Holiday

01/01 NewYearsDay

01/15 MartinLutherKingJr.Day

02/19 President’sDay

03/30 GoodFriday

05/28 MemorialDay

07/04 IndependenceDay

09/03 LaborDay

11/11 Veteran’sDay

11/22 ThanksgivingDay

11/23 FridayAfterThanksgivingDay

12/24 ChristmasEve

12/25 ChristmasDay

12/31 NewYearsEve



USDA Nondiscrimination Statement

In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex, disability, age, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA. Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English. To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) found online at: http://www.ascr.usda.gov/complaint_filing_cust.html, and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by: (1) mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410; (2) fax: (202) 690-7442; or (3) email: [email protected]. This institution is an equal opportunity provider.





Child & Adult Care Food Program

Child Enrollment Form

State of Alaska Teaching and Learning Support

Child Nutrition Programs (907) 465-8711 (907) 465-8910

Institution Name:__________________________________________________________ ________CIS/CACFP Number Facility/Provider Name:_______________________________________ Dear Parent/Guardian, Your day care facility participates in the U.S. Department of Agriculture (USDA) Child and Adult Care Food Program (CACFP). CACFP needs verification of enrollment for each participant in this facility. Please complete the table below for all participants in your household that are enrolled at this facility. The information below should be completed by the parent/guardian. Please use the guides below the table to complete and sign and date the form below.

Child’s First Name Child’s Last Name Date of Birth

Normal/Typical Hours of Care

Normal/Typical Days of Care (Circle all that apply)

Meals Normally Eaten (Circle all that apply)

_____ to _____ M T W TH F Sat Sun B AM L PM S LPM





Guide: Normal hours of care: Insert the usual arrival time and the usual departure time. Indicate a.m. or p.m. Normal days of care: Circle the days of the week the participant(s) are usually in attendance at the facility. (M=Monday; T=Tuesday; W=Wednesday; TH=Thursday, F=Friday, Sat=Saturday, Sun=Sunday) Meals Normally Eaten: Circle the meals the participant(s) usually eat at the facility. (B=Breakfast; AM=AM Snack; L=Lunch; PM=PM Snack; S=Supper; LPM=Late PM/Evening Snack) Parent/Guardian Signature:___________________________________ Date:_____________ Print Name:_____________________________________ Address:________________________________________ City:____________ Zip Code:________________ Home Telephone Number ( ) __________________ Work Telephone Number: ( ) ______________

For Facility/Provider Use Only: Signature of Facility Representative/Provider:_______________________________________ Date:____________ Date the participant withdrew:_________________

The U.S. Department of Agriculture prohibits discrimination against its customers, employees, and applicants for employment on the bases of race, color, national origin, age, disability, sex, gender identity, religion, reprisal, and where applicable, political beliefs, marital status, familial or parental status, sexual orientation, or all or part of an individual’s income is derived from any public assistance program, or protected genetic information in employment or in any program or activity conducted or funded by the Department. (Not all prohibited bases will apply to all programs and/or employment activities.) If you wish to file a Civil Rights program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, found online at http://www.ascr.usda.gov/complaint_filing_cust.html, or at any USDA office, or call (866) 632-9992 to request the form. You may also write a letter containing all of the information requested in the form. Send your completed complaint form or letter to us by mail at U.S. Department of Agriculture, Director, Office of Adjudication, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, by fax (202) 690-7442 or email at [email protected]. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339; or (800)845-6136 (Spanish).

Documents

First Day Checklist · ☐ My child is enrolled _____ Program (OCS, CITC, P1, P2, other). I understand that it is my responsibility to provide a current authorization as needed. I