1LITTLE ANGELS MONTESSORI PRESCHOOL & DAY CARE CENTER

208 South Plaza Trail Virginia Beach, VA 23452 (757) 486-3322

Child

Nickname Date of Birth Sex

Address

Chronic Physical Problems/Pertinent Developmental Information/ Special Accommodations Needed

Previous Child Day Care Programs and Schools Attended

If Child attends this Center and Another School/Program, Give the Name of the School/Program

Parent(s)/Guardian(s)

Father

Place Employed Business Phone Cellphone

Home Address

Home Phone

Mother

Place Employed Business Phone Cellphone

Home Address

Home Phone

Father’s Email Address

Mother’s Email Address

Person(s) or Agency Having Legal Custody of Child

Cell Phone

Home Address

Business Phone Home Phone

Emergency Information

Allergies or Intolerance to Food, Medication, etc. and Action to take in an Emergency

Child’s Physician

Phone

Two People to be Contact if Parent(s) Cannot Be Reached

1.

Address Phone

2.

Address Phone

Person(s) Authorized to Pick Up Child

Person(s) NOT Authorized to Pick Up Child*

Appropriate paperwork such as custody papers shall be attached if there are any restrictions on parent pick up.

AGREEMENTS

1. The child day center agrees to notify the parent(s)/guardian(s) whenever the child becomes ill and the

parent(s)/guardian(s) will arrange to have the child picked up as soon as possible if to requested by the

center.

2. The parent(s)/guardian(s) authorize the child day center to obtain immediate medical care if any

emergency occurs when the parent(s)/guardian(s) cannot be located immediately.**

3. The parent(s)/guardian(s) agree to inform the child day center within 24 hours or the next business day

after his/her child or any member of the immediate household has developed any reportable

communicable disease, as defined by the State board of Health, except for life threatening diseases which

must be reported immediately.

4. Other: ______________________________________________________________________________

SIGNATURES _____________________________________________ _______________________

Parent(s) or Guardian(s) / Social Security # XXX-XX- ___ ___ ___ ___ Date

_____________________________________________ _________________

Administrator of Center Date

Date Child Entered Care: _______________ Date Child Left Care: _______________

**If there is an objection to seeking emergency medical care, a statement should be obtained from the parent(s) or guardian(s)

that states the objection and the reason for the objection

OFFICE USE ONLY

IDENTITY IDENTIFICATION

If proof of identify is required and a copy is not kept, please fill out the following:

Place of Birth Birth Date Birth Certificate # Date Issued

Other Form of Proof Date Documentation

Viewed Person Viewing Documentation

Date of Notification of Law-Enforcement Agency (when required of identity is not provided): Date: _____________

Proof of the child’s identity and age may include a certified copy of the child’s birth certificate, birth

registration card, notification of birth (hospital, physician or midwife record), passport, copy of the

placement agreement or other proof of the child’s identity from a child placing agency (foster care and

adoption agencies), record from public school in Virginia, certification by a principal or his designee of a

public school in the U.S. that is a certified copy of the child’s record that was previously presented or

copy of the entrustment agreement conferring temporary legal custody of a child to an independent foster

parent. Viewing the child’ proof of identify is not necessary when the child attends a public school in

Virginia and the center assumes responsibility for the child directly from the school (i.e. after school

program) or the center transfers responsibility of the child directly to the school (i.e. before school

program). While programs are not required to keep the proof of the child’s identity, documentation of

viewing this information must be maintained for each child.

SERVICE AGREEMENT

We have reserved a place for your child, ______________________________ for

______ days per week, ______________________, beginning ____________________.

Tuition is $_____________ per week for the:

_____ Full day program is due in advance every Monday. Parent agrees to pay a $20.00 late

charge if tuition is paid after Tuesday of that week. Parent understands there is no reduction of

fees or tuition for absences, designated school holidays, or closing due to inclement weather. If

____________________ is absent one day, the fee is the same. Parent agrees to pay a late fee of

$10.00 for the first five minutes then $1.00 per minute after if picked up after 6:30pm.

_____ Part time program is due in advance every Monday. Parent agrees to pay a $20.00 late

charge if tuition is paid after Tuesday of that week. Parent understands there is no reduction of

fees or tuition for absences, designated school holidays, or closing due to inclement weather. If

___________________ is absent one day, the fee is the same. Parent agrees to pay a late fee of

$10.00 for the first five minutes then $1.00 per minute after if picked up after 12:30pm.

__________________________________ _________________

PARENT OR GUARDIAN SIGNATURE DATE

_________________________________ _________________

DIRECTOR DATE

CHILD’S EMERGENCY MEDICAL AUTHORIZATION

Name of Child: ____________________________________ Date of Birth: ________________

Home Address: _________________________________________________________________

Home Phone: ______________________

Mother’s Name: _______________________________________ Cell Phone_______________

Place of Employment:_______________________________ Business Phone________________

Address: ______________________________________________________________________

Father’s Name:_______________________________________ Cell Phone _______________

Place of Employment:_______________________________ Business Phone _______________

Address: ______________________________________________________________________

The Parent(s)/Guardian(s) authorized Little Angels Montessori Preschool to obtain immediate

medical care and consents to the hospitalization of, the performance of necessary diagnostic test

upon, the use of surgery on, and/or the administration of drugs to, his/her child or ward if an

emergency occurs when s/he cannot be located immediately. It is also understood that this

agreement covers only those situations which are true emergencies and only when s/he cannot be

reached. Otherwise, s/he expects to be notified immediately.

1. I/we will be responsible for the payment of medical care expenses:______________________

2. Medical treatment costs are covered by:

a. Private Insurance (Name & Policy Number) __________________________________

b. Medicaid Coverage Number: _____________________________________________

c. Other Medical Insurance (Name & Policy Number) ____________________________

____________________________

d. No Insurance: __________

Child’s Physician/Clinic Attended: _________________________________________________

Attached is a copy of the agreement with:

Child’s parent(s) or guardian(s) and the day care center operator. Yes____ No_____

__________________________________ _________

Parent’s or Guardian’s Signature Date

*This form is to be kept by the day care operator and is to be taken to the doctor or treatment

facility in case of emergency.*

AUTHORIZATION FOR EMERGENCY TREATMENT

Permission for the Director, Acting Director, or the teacher to take whatever

steps may be necessary for medical care in case of an emergency is hereby given. I

understand that the order of actions taken will follow the outline below unless there

is need for immediate action, but will not be limited to these actions:

1. Parent or guardian will be called

2. Child’s physician will be called

3. Contact person parents have listed will be called

4. If none of these efforts are successful:

a. Another physician will be called

b. An ambulance will be called

c. The child will be taken to the emergency room of

_______________________ accompanied by a staff member.

5. In order for the school to assume responsibility for my child, I understand

that I must sign the child in at arrival time and out at departure time.

_________________________________ _______________

Parent’s or Guardian’s Signature Date

_________________________________ _______________

Director Date

FIELD TRIP AND ACTIVITIES PERMISSION SHEET

I give permission for my child to participate in the neighborhood walks or

field trips in an authorized vehicle. I understand that I will be informed of all

planned field trips that I may withdraw my permission for a planned trip if I so

desire.

I grant permission for my child to be included in school pictures and give

permission for those pictures to be used by the center.*

*This includes the use of pictures/videos on our website or on our social

media sources.

I grant permission for my child to participate in the activities and in the use

of the equipment at the center.

I grant permission for my child to play at the public playground used by the

center or grassy areas located on the property.

I grant permission for my child to play in a child’s wading pool that will not

contain greater than six (6) inches of water.

_______________________________ _____________

Parent’s or Guardian’s Signature Date

Enrollment Checklist

Registration Forms COMPLETELY FILLED OUT (No Blanks Please)

Updated Shot Record (upon entry)

School Physical Form signed by Physician (due within 30 days after entry)

Birth Certificate/Birth Letter or Proof of identity

Crib Sheet and blanket (nap time)

Change of Clothes (for accidents and spills)

School Supplies

Sign up for Text Messages!

Using Remind, a free texting service, Little Angels will be able

to send reminders/closings/ information text messages to your

phone! If you would like to sign up for text alerts, please write your cell phone number

beginning with area code.

Mother’s Cell phone

Phone Number beginning with area code

Father’s Cell phone

Phone Number beginning with area code

PARENT’S HANDBOOK CHECKLIST

In order to assure that parents clearly understand the policies of the school, we ask all parents to

read the Little Angels Parent’s Handbook thoroughly. Please sign below.

1. There is no reduction of fees for absences, designated school holidays, or closures due to inclement weather.

2. There will be a $30.00 charge for each returned check. After two returned checks, tuition must be paid in

cash or card.

3. Parent, guardian, or responsible designated adult must sign the child in and out each day and must make sure

the teacher knows when they arrive and leave each day. (Please be aware that we cannot assume responsibility

of allowing any child to leave persons under 18 years of age.)

4. The child must be kept at home for 24 hours if any of the following exists: a temperature of 101 degrees or

more, intestinal disturbances accompanied by diarrhea or vomiting, any undiagnosed rash, sore or discharging

eyes, or ears, profuse nasal discharge or a child that is too sick to participate in the full program, including

outdoor activities.

5. Parents or guardian must furnish 2 coverings for nap (sheet AND blanket), and a complete change of

clothing at all times, with the child’s name on each item.

6. Parents or guardian must inform the school of changes in address, phone number, (work or home)

employment, or emergency information.

7. Food may not be brought to school except in cases of allergies, religious beliefs or pre-approved

celebrations.

8. Toys may not be brought to school except on show and tell day (Friday).

9. Tuition is due every Monday in advance and a $20.00 late fee will be assessed if not paid by Tuesday.

10. The director is to be notified two weeks in advance before a child is to be withdrawn. Parents are required

to pay those two weeks regardless of when the child leaves school.

11. Parents or guardian agrees to dress the child in accordance with the school dress code.

12. If after reasonable period of time, it is found that a child is unable to adjust to the Center, the Center

reserves the right to request withdrawal for the child. This decision is left to the discretion of the Director.

13. A late pick up fee of $10.00 per 5 minutes then $1.00 per minute after will be charged after closing time.

The late-fees go directly to the teachers that had to stay late waiting on you to pick up your child.

14. If a child is to receive any medication during the school day, the parent or guardian must have completed a

Medication Authorization form. Sunscreen/sun block lotion and insect repellent also requires a Medication

Authorization form.

14. I agree to abide by these rules and regulations.

15. I have received the Parents Handbook.

________________________________________ _____________________

Signature of Parent of Guardian Date

Little Angels Montessori Preschool & Day Care Center

Pre-Admission Background Information

*The center staff needs your help to understand and plan for your child. Please fill out the

following form and return it to the center before enrollment.

Child’s Name: _______________________________________ Nickname: _________________

Date of Birth: ________________________________ Age: ____________________________

Address:______________________________________________________________________

Home Phone Number: _____________________________

Mother’s Name: _____________________________________ Cell Phone: ________________

Occupation: ______________________________________ Business Phone: _______________

Father’s Name: ______________________________________ Cell Phone: ________________

Occupation: ______________________________________ Business Phone: _______________

Family Data

Are parents together? _____ Separated/Divorced? ____ Mother living? ___Father Living? _____

Members of the family (parent(s), brothers, sisters, grandparents, etc) living at home:

Name Age Relationship Indicated Name used by child

__________________ __________ _______________________ ___________________

__________________ __________ _______________________ ___________________

__________________ __________ _______________________ ___________________

__________________ __________ _______________________ ___________________

Health

Does your child have any disabilities? __________ If so, please state: ____________________

Does your child wear glasses? _________ Wear a hearing aid? ___________

Previous Schooling

Has your child had any previous school experience? Yes ____________ No ______________

If so, please give name and type of school.

School: ___________________________________ Length of Attendance: _________________

Sleep Habits

Does your child take a nap? Yes_______ No _______ Morning _______ Afternoon ______

Approximately how many hours does your child sleep at night? ___________

Toileting

Is your child potty trained? Yes _______ No ________Words child uses for potty ___________

Nutritional Patterns

Describe your child’s appetite:

_____ always hungry _____ never hungry _____ snacks ______ snacks all day ______

eats at meal time _____ has to be coaxed to eat

Are there any foods your child may not or cannot eat? (due to allergies, religious, customs, etc.)

Yes _________ No __________ If so, please state: ___________________________________

Are there any foods your child dislikes? Yes _____ No _____

______________________________________________________________________________

Interests

Child’s Special Interests: _____ singing ______ painting ______ stories _____

trucks _____ pets ______ Music ______ outside play ______ coloring ______

other: ________________________________________________________________________

Social Development

Is your child generally:

______ cooperative _____ shy _____ competitive _____ happy

_____ aggressive _____ sensitive _____ submissive _____ angry _____ friendly

_____ active ______ outgoing

Does your child usually do what is asked of him/her? ___________

Whines?___________ Temper tantrums? ____________

If so, how do you handle them?

______________________________________________________________________________

Does your child have special fears?

______________________________________________________________________________

How does your child respond to a stressful situation?

______________________________________________________________________________

What seems to make your child feel better?

______________________________________________________________________________

List other behavior characteristics of your child/anything else you would like us to know

about your child:

______________________________________________________________________________

______________________________________________________________________________

*Please fill out completely. No Blanks Please* Date: ________________________

Please help us update our files by furnishing the following emergency information.

Child’s Name: _____________________________________________ DOB: _______________

Current Address: _____________________________ Home Phone: ____________________

Father’s Name: _______________________ Mother’s Name: _________________________

Employer: ___________________________ Employer: ______________________________

Work Phone: _________________________ Work Phone: ____________________________

Cell Phone: __________________________ Cell Phone: _____________________________

e-mail: ______________________________ e-mail: _________________________________

Emergency Contacts: Two people to contact if parent(s) cannot be reached

1. Name: ___________________________________ Phone Number(s): _________________

Address: ____________________________________

____________________________________

2. Name: ___________________________________ Phone Number(s): _________________

Address: ____________________________________

____________________________________

Persons Authorized to Pick Up Child:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Medical

Allergies/Intolerance to Food, medication, etc:

______________________________________________________________________________

Child’s Physician: ______________________________ Phone Number: ___________________

*This form is to be kept by the day care operator and is to be taken to the doctor or treatment

facility in case of an emergency.*

*This form is to be kept by the day care operator and is to be taken to the doctor or treatment

facility in case of an emergency.*

CHILD’S EMERGENCY MEDICAL AUTHORIZATION

The Parent(s)/Guardian(s) authorized Little Angels Montessori Preschool to obtain immediate

medical care and consents to the hospitalization of, the performance of necessary diagnostic test

upon, the use of surgery on, and/or the administration of drugs to, his/her child or ward if an

emergency occurs when s/he cannot be located immediately. It is also understood that this

agreement covers only those situations which are true emergencies and only when s/he cannot be

reached. Otherwise, s/he expects to be notified immediately.

1. I/we will be responsible for the payment of medical care expenses:______________________

2. Medical treatment costs are covered by:

a. Private Insurance (Name & Policy Number) __________________________________

b. Medicaid Coverage Number: _____________________________________________

c. Other Medical Insurance (Name & Policy Number) ____________________________

____________________________

d. No Insurance: __________

Child’s Physician/Clinic Attended: _________________________________________________

AUTHORIZATION FOR EMERGENCY TREATMENT

Permission for the Director, Acting Director, or the teacher to take whatever steps may be

necessary for medical care in case of an emergency is hereby given. I understand that the order

of actions taken will follow the outline below unless there is need for immediate action, but will

not be limited to these actions:

1. Parent or guardian will be called

2. Child’s physician will be called

3. Contact person parents have listed will be called

4. If none of these efforts are successful:

a. Another physician will be called

b. An ambulance will be called

c. The child will be taken to the emergency room of _______________________

accompanied by a staff member.

5. In order for the school to assume responsibility for my child, I understand that I must sign

the child in at arrival time and out at departure time.

_________________________________ _______________

Parent’s or Guardian’s Signature Date