Kindercare Enrollment Form – Fill Out and Use This PDF

ENROLLMENT AGREEMENT

WELCOME TO KINDERCARE!

You’ve made a great choice for your child! We’re honored to become a part of your child’s early learning experiences—and we’re excited to get to know you, your family members, and the other important people in your child’s life.

This enrollment form ensures that we all have the best start possible. We also need this information to comply with child care licensing regulations. (Please don’t hesitate to request a copy of those regulations if you’d like.) We’ll also set up a time to review our Family Handbook with you very soon.

The most important thing we want you to know is this: We are committed to making your time with us a positive one. Please call us any time, no matter how small your question may seem—especially in the irst few weeks, as your family gets used to

a new routine.

Welcome again! We’re so glad you’re here.

TELL US ABOUT YOUR CHILD

First Name	Middle		Last	Nickname
Date of Birth	Gender		Language spoken at home
	 Female	 Male
Child’s home address				Home phone

Please list family members your child lives with, including the names and ages of siblings:

TELL US ABOUT YOU

The safety of children in our centers is our top priority. Center staff will release your child only to the parents and guardians listed—or to the other emergency contacts you authorize below.

If you do need to authorize a new pickup person by phone, you may do so—but we will ask you to answer the two security questions you provide here to verify your identity. For your child’s safety, any time a person we do not recognize comes to pick up your child, we will ask for a government-issued photo ID.

WHO ARE EMERGENCY CONTACTS AUTHORIZED TO PICK UP YOUR CHILD (18 or older)?

Our goal is to provide your child excellent education and care. We have a few questions that will help us be better prepared to meet your child’s individual needs. Please indicate if your child receives any of the following supports:

Is there anything else we need to know about your child to ensure he or she can be well supported by our staff?

MY CHILD’S MEDICAL CARE PROVIDER

Medical Care Provider name	Practice / Clinic name
Provider address		Phone
Preferred hospital / clinic
Dentist name
Address		Phone
Health Insurance Provider and policy number

MY CHILD’S ALLERGIES

 Medications						Reaction
 Food						Reaction
 Respiratory						Reaction
 Bee sting						Reaction
 Other						Reaction
Are any of the allergies severe or life-threatening?					 Yes  No (If yes, please talk to your Center Director about completing an allergy plan.)
MEDICAL ACKNOWLEDGMENTS

1.Medication I will provide written permission for center staff to administer medication with written instructions from me or the child’s health care provider, as permitted by local child care licensing regulations. I will complete and sign authorization forms. I will provide the medication in its original container (with the pharmacist’s label for prescriptions).

2.Immunizations I will provide the center with updated immunization information or an exemption for my child.

3.Nurse/Health Consultant Child care centers in some states are required to engage the services of a Nurse/Health Consultant to review health policies and procedures and children’s records. I agree my child’s records may be reviewed by the nurse/health consultant.

4.Illness If center staff notiies me that my child is ill, I will pick up my child as soon as possible and no later than one (1) hour after being contacted. If my child contracts a contagious illness, I understand that my child may return only when he or she is well, as described in the Family Handbook.

5.Emergencies In case of an emergency, I understand that center staff will attempt to contact me immediately. I also authorize center staff to:

•Consult the physician or dentist named above.

•Administer irst aid and/or cardiopulmonary resuscitation.

103545-OPS-GEN-KC 6/15 © 2006-2015 Knowledge Universe Education LLC. All rights reserved.

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CENTER HOURS

The center is open from a.m. to p.m., through .

Most centers will be closed New Year’s Day, Memorial Day, Fourth of July, Labor Day, Thanksgiving and day after, as well as Christmas Day. We also dedicate time every year for professional development. Your Center Director will inform you when your center will be closed for these training days. The center will be open whenever possible on a regularly scheduled day, except in the case of severe weather or other emergency. Tuition is not reduced as a result of center closures.

TRANSPORTATION INFORMATION (For School-Age Children Only)

SCHEDULE AND TRANSPORTATION ACKNOWLEDGMENTS

1.Transportation Changes I agree to notify the center if my school-age child does not need to be picked up from school or will not arrive by scheduled school bus on a particular day.

2.Regular Schedule Tuition is based on the child’s regular schedule. I will be charged additional tuition if my child’s attendance increases beyond this schedule. If my child’s schedule changes in any way, I will notify the center immediately. Tuition and fees are not pro-rated for illness, holidays, or emergency closures. I agree to pay the full tuition even if my child is absent for one or more days, except for pre-arranged “reservation weeks.”

3.Absences I will notify the center by 9:00 am when my child will be absent.

4.Child Not Picked Up If I fail to pick up my child and/or contact the center, and I or another authorized person cannot be reached within 30 minutes after closing time, center staff may release my child to the custody of child protective services or other local authorities.

TUITION AND FEE INFORMATION

•	Late Payment Fee All tuition is due in advance. In-center tuition payments are due by the close of business on the Friday prior to service,
	and online tuition payments are due by 11 pm PT the Sunday prior to service. If tuition is not paid on time, a late fee of $										will
	be charged.
•	Registration Fee A nonrefundable annual registration fee of $						is due at the time of enrollment and payable each year on
	or before September 1. If your child is withdrawn from the program and later re-enrolls, a new registration fee is due at that time.
•	Reservation Week Fee If you know your child will be absent for a full week, you may use a reservation week instead of paying full tuition.
	Reservation week fees are equivalent to a			% discount on full tuition. Your center offers					reservation weeks per year.
•	Late Pick-Up Fee A late pick-up fee of $				per child will be assessed when a child is left beyond the center’s operating

hours. The late pick-up fee is not an agreement to provide after-hours service.

•Additional Fees Your child may have the opportunity to participate in special programs, summer programs, or ield trips with an additional fee.

•School-Age Care Fees If your child regularly attends elementary school but school is not in session due to a school holiday, closure,

or early release, he or she may attend a full/half day at the center for an additional $				per day or $			per half
day. When school is not in session for the entire week, full-time tuition is $			per			.

Parent/Guardian Signature

Date

103545-OPS-GEN-KC 6/15 © 2006-2015 Knowledge Universe Education LLC. All rights reserved.

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FINANCIAL ACKNOWLEDGMENTS

1.Payment Authorizations I authorize KinderCare to:

•Use my tuition and fee payment checks to initiate electronic debits to my checking account.

•Attempt to collect on returned checks up to two additional times.

•Electronically debit my account for the amount of any returned item and a returned item fee in the maximum amount allowed by state law.

•Initiate one-time ACH debits to my checking account for any amounts owed that become past due (upon written notice from the center.)

My payment authorizations will remain in effect until I give the center written notiication to terminate the authorization.

2.Financial Obligations

As the parent/guardian signing this Enrollment Agreement all amounts due are ultimately my responsibility.

Overdue accounts may be referred to a collection agency. I am responsible for all account balances, plus reasonable collection and attorney fees associated with the collection of the account.

Payments from families with prior unpaid returned checks must be in the form of a money order or cashier’s check. Families with returned check activity may be subject to immediate termination of services.

Any prepaid balance of $25 or less which remains at the time of my child’s disenrollment will not be refunded unless requested in writing within 90 days.

Two weeks’ written notice is required prior to the last day of attendance. If I do not give two weeks’ written notice of withdrawal, I agree to pay full tuition and fees due for the inal two weeks regardless of my child’s attendance.

PHOTOGRAPHY OF CHILDREN

I give permission for my child to be photographed and videoed in the center and during program functions and ield trips. I understand that photographs/videos may be taken by center staff or by

other parents/guardians, and I consent to the use of these photographs/videos for communication

purposes, such as communication with families and internal business communications.	Parent/Guardian Initials
OTHER TERMS
Assessments and Screenings

I give permission for my child to participate in early learning assessments and screenings administered by KinderCare. The results of these assessments will be used by KinderCare to measure my child’s progress and may be used to evaluate, market and update KinderCare’s programs. I will have access to all results of these assessments.

Babysitting

We don’t encourage private babysitting by our staff. If you hire any of our employees, however, how that works is solely between you and the employee. KinderCare is not responsible for those services.

Communications

I give KinderCare permission to communicate with me by telephone, text, e-mail, or other means. I understand KinderCare’s privacy policy applies to the information I provide (www.kueducation.com/us/privacy-policy).

Resolving Disputes

We do not expect any disagreements. However, we agree that, in the unlikely event we have one we can’t resolve, any dispute or claim will be submitted to nonbinding mediation before beginning arbitration, litigation, or any other proceeding. We agree to act in good faith to participate in mediation and to identify a mutually acceptable mediator. All parties to the mediation will share equally in its costs.

I have read, understand and accept all of the terms in this Agreement. I will promptly update any information provided for in this Agreement if any information changes. Center management does not have the authority to change the terms of this Agreement (other than inserting information where required) either verbally or in writing. A child may be dis-enrolled by the center without prior notice if, in the sole opinion of the center, it is in the best interest of the child or the center. We reserve the right to alter policies and/or program at any time. The terms of this Agreement, including the tuition and fees, are subject to change in whole or in part by the center with 30 days’ notice.

103545-OPS-GEN-KC 6/15 © 2006-2015 Knowledge Universe Education LLC. All rights reserved.

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