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1 Children’s Learning Center at Mitchell College Registration Form 2019/2020 Contact us at [email protected] Children’s Learning Center at Mitchell College REGISTRATION & ENROLLMENT FORM 2019/2020 School Year Current Date: __________________________ Anticipated Enrollment Date: ____________________________ Child’s Name: (First, Middle, Last) _______________________________________________________________ Name to be called at school: __________________________ Gender: M/F Date of Birth: _________________ Child’s Physical Address: ______________________________________________________________________ Information to be completed by parent/guardian. ANY revisions or a change of information requires a revised form. Preschool staff is only responsible for providing information noted on this form to emergency personnel. PARENTS: This form requires both parents’ information unless child is in the custody of only one parent; copy of custody papers is required to be on file at the Children’s Learning Center. Parent/Guardian: ___________________________________________________________________________ Home Address: _____________________________________________________________________________ City/State: __________________________________________________ Zip code: ______________________ Work Phone #: _________________ Cell Phone #: ___________________ Home Phone #:_________________ Driver License Number: ____________________Email address: ______________________________________ Employer: _________________________________________________________________________________ Employer Address: ______________________________________City/State: ___________________________ Parent/Guardian: ___________________________________________________________________________ Home Address: _____________________________________________________________________________ City/State: __________________________________________________ Zip code: ______________________ Work Phone #: _________________ Cell Phone #: ___________________ Home Phone #:_________________ Driver License Number: ____________________Email address: ______________________________________ Employer: _________________________________________________________________________________ Employer Address: ______________________________________City/State: ___________________________

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Page 1: Children’s Learning Center at Mitchell College...1 Children’s Learning Center at Mitchell College Registration Form 2019/2020 Contact us at clc@mitchell.edu Children’s Learning

1Children’sLearningCenteratMitchellCollegeRegistrationForm2019/[email protected]

Children’sLearningCenteratMitchellCollege

REGISTRATION&ENROLLMENTFORM2019/2020SchoolYear

CurrentDate:__________________________AnticipatedEnrollmentDate:____________________________

Child’sName:(First,Middle,Last)_______________________________________________________________

Nametobecalledatschool:__________________________Gender:M/FDateofBirth:_________________

Child’sPhysicalAddress:______________________________________________________________________

Informationtobecompletedbyparent/guardian.ANYrevisionsorachangeofinformationrequiresarevisedform.Preschoolstaffisonlyresponsibleforprovidinginformationnotedonthisformtoemergencypersonnel.PARENTS:Thisformrequiresbothparents’informationunlesschildisinthecustodyofonlyoneparent;copyofcustodypapersisrequiredtobeonfileattheChildren’sLearningCenter.Parent/Guardian:___________________________________________________________________________

HomeAddress:_____________________________________________________________________________

City/State:__________________________________________________Zipcode:______________________

WorkPhone#:_________________CellPhone#:___________________HomePhone#:_________________

DriverLicenseNumber:____________________Emailaddress:______________________________________

Employer:_________________________________________________________________________________

EmployerAddress:______________________________________City/State:___________________________

Parent/Guardian:___________________________________________________________________________

HomeAddress:_____________________________________________________________________________

City/State:__________________________________________________Zipcode:______________________

WorkPhone#:_________________CellPhone#:___________________HomePhone#:_________________

DriverLicenseNumber:____________________Emailaddress:______________________________________

Employer:_________________________________________________________________________________

EmployerAddress:______________________________________City/State:___________________________

Page 2: Children’s Learning Center at Mitchell College...1 Children’s Learning Center at Mitchell College Registration Form 2019/2020 Contact us at clc@mitchell.edu Children’s Learning

2Children’sLearningCenteratMitchellCollegeRegistrationForm2019/[email protected]

LocalEmergencyContact:(First,Last)___________________________________________________________

Relationshiptochild:__________________________HomePhone#:________________________________

CellPhone#:_________________________________WorkPhone#:_________________________________

ADDITIONALPEOPLEAUTHORIZEDTOPICKUPCHILDFROMCENTER:(PhotoI.D.Required)

Name:(First/Last)______________________________________Relationshiptochild:___________________

HomePhone#:________________CellPhone#:____________________WorkPhone#:__________________

Name:(First/Last)______________________________________Relationshiptochild:___________________

HomePhone#:_________________CellPhone#:___________________WorkPhone#:__________________

PersonsUNAUTHORIZEDtopickupChild:

Name:(First,Last)___________________________________________________________________________

BriefDescription:___________________________________________________________________________

CulturalDemographics:

IsyourchildHispanic/Latino?Yes_____No_____

Race(checkallthatapply):AmericanIndianorAlaskanNative_______AsianAmerican_______

BlackorAfricanAmerican_______NativeHawaiianorOtherPacificIslander_______White_______

AdditionalInformation:

Hasthechildattendedpreschoolbefore?Yes_____No_____

Ifyes,pleaseprovidenameofschoolandatwhatagethechildattended:__________________________________________________________________________________________

Isyourchildtoilettrained?Yes_____No_____

Doesthechildhaveanyspecialmedicalcondition,allergies,orneeds?Yes_____No_____

Ifyes,pleasedescribe:____________________________________________________________________________________________________________________________________________________________________________________

Doesthechildhaveanyidentifiedspecialeducationalneeds?Yes_____No_____

Ifyes,pleasedescribe:__________________________________________________________________________________________

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3Children’sLearningCenteratMitchellCollegeRegistrationForm2019/[email protected]

Arethereotherchildreninthehousehold?(Includenamesandbirthdates)____________________________________________________________________________________________________________________________________________________________________________________

Whatlanguagedidthechildlearntospeakfirst?___________________

Whatistheprimarylanguagespokeninthechild’shome?___________________

Whatotherinformationregardingyourchild’slifeexperiencescanyousharethatwillallowustomeetyourchild’sneeds?Isthereanythingelseyouthinkweshouldknowaboutthechild?(Specialinterests,experiences,homelife,etc.)______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

PAYMENTIunderstanditismyresponsibilitytopayforservicesrendered.Paymentisduebycheckorcreditcard,online,bycloseofbusinessFridayfortheweekahead.Accountsareconsidereddelinquentwhenoverduebyoneweek.Alatefeeof$25willbeassessedbycloseofbusinessFridaytoallaccountsoverdue.Initial________Failuretopaywillresultinthisaccountbeingturnovertocollectionsandthechildbeingdismissedfromcare.Alllegalexpensesincurredinanattempttocollectpaymentsforthisaccountwillalsobemyresponsibility.Initial_________PHOTO/MEDIARELEASEIgiveapprovaltousepictures/videotakenofmychildforthebulletinboardsandspecialprojectsintheclassroom.Initial________Igiveapprovaltousepictures/videotakenofmychildforpublicityoradvertisementsincludinginternetbasedproductsandpromotions.Initial_________PARENTHANDBOOK&BEHAVIOR/DISCIPLINEPOLICYIacknowledgereceivingtheparenthandbookandwillabidebythepoliciesthatarewrittentohelpmaintainaqualitychildcarecenterformychild.Initial_________IalsohavehaddiscussionandunderstandCenter’sBehavior&DisciplinePolicyInitial_________WALKINGPERMISSIONSLIPIgivepermissionformychildtoparticipatein“walking”fieldtripsaroundtheareaofMitchellCollegeChildren’sLearningCenter.Initial_________Mayweaddyourcontactinformationtoourclasslisttobesharedwithotherfamiliesinyourchild’sclass?Y/NHowdidyouhearofus?

Page 4: Children’s Learning Center at Mitchell College...1 Children’s Learning Center at Mitchell College Registration Form 2019/2020 Contact us at clc@mitchell.edu Children’s Learning

4Children’sLearningCenteratMitchellCollegeRegistrationForm2019/[email protected]

Note:A$50.00non-refundableregistrationfeemustaccompanythisform.AnEarlyChildhoodHealthAssessmentRecordincludingimmunizations,mustbecompletedbyahealthcareprofessionalwithacompletephysicalexampriortothechild’santicipatedenrollmentdate.YoumaydownloadtheConnecticutstateformathttp://www.ct.gov/oec/lib/oec/licensing/childcare/cdc_childhlthassessrcd.pdf.DAYSANDTIMESMYCHILDWILLATTENDTheChildren’sLearningCenteratMitchellCollegewillbeopenMondaythroughFridayfrom7:00amuntil6:00pm.FullDayPreschoolhoursare8:00amuntil4:00pm;beforecareandaftercareforFullDayprogramisavailableandincludedinyourtuition.HalfDayPreschoolhoursare8:00amuntil1:00pm;limitedbeforecareandaftercareforHalfDayprogramisavailablefor$10perhourperchild.

YoumaychooseeitherM-FFullDayprogramorM-FHalfDayprogram.Scheduledschoolclosuresandeventsarepostedonourwebsiteathttp://mitchell.edu/clc-calendar-19-20

The2019-2020schoolyearbeginsAugust26,2019andour2020summerprogrambeginsJune21,2020.

MychildwillbeattendingFull-Day,MondaythroughFriday MychildwillbeattendingHalfDay,MondaythroughFriday,from8am-1pm

Days Monday Tuesday Wednesday Thursday FridayFrom ______a.m./p.m. ______a.m./p.m. _______a.m./p.m. _______a.m./p.m. _______a.m./p.m.

To ______a.m./p.m. ______a.m./p.m. _______a.m./p.m. _______a.m./p.m. _______a.m./p.m.

RATES$205perweekperchildforFullDay(8am-4pm,M-F);beforecare(7-8am)&aftercare(4-6pm)isincluded.$155perweekperchildforHalfDay(8am-1pm,M-F);limitedbeforecare&aftercareis$10perhourperchild$40materialsfeeperchild$10perweekadditionalfeeforachildwhoisnotfullypotty-trained10%discountformorethanonechild;discountappliedtohigherpricedtuitionMitchellCollegefaculty&staffreceivebeforecareandaftercareatnoadditionalchargeCompleteandsubmitallformswithnon-refundable$50registrationfee:

• Checkmadepayableto:“MitchellCollege”with“CLC”inthememoChildren’sLearningCenteratMitchellCollege437PequotAvenueNewLondon,CT06320

Page 5: Children’s Learning Center at Mitchell College...1 Children’s Learning Center at Mitchell College Registration Form 2019/2020 Contact us at clc@mitchell.edu Children’s Learning

5Children’sLearningCenteratMitchellCollegeRegistrationForm2019/[email protected]

Children’sLearningCenteratMitchellCollegeEMERGENCYMEDICALINFORMATION&CONSENTMEDICALINFORMATION(Parentisresponsibleforprovidinganupdatedformwheninformationchanges)Noteanyallergiesorpertinenthealthconditionsthatemergencypersonnelshould

know.(BeeStings,allergies,asthma,medicationss/heistaking,diabetes,etc.)IunderstandthatifmychildisallergictoanythingrequiringtheuseofanEpi-Pen,ImustbringanEpi-PentotheChildren’sLearningCentertokeeponsite.____________________________________________________________________________________________________________________________________________________________________________________PHYSICIANINFORMATIONChild’sPhysician:______________________________________________Phone:_______________________Child’sDentist:________________________________________________Phone:_______________________PreferredHospital:__________________________________________________________________________INSURANCEINFORMATIONInsuranceName:______________________________NameInsuredUnder:____________________________InsuranceIdentificationNumber:_________________________InsurancePhone#:_____________________PERMISSIONTOSEEKCAREIunderstandthateveryeffortwillbemadetocontactmeintheeventofanemergencyrequiringmedicalattention.IunderstandtheteachersinthechildcarecenteraretrainedinthebasicsofFirstAidandIauthorizethemtogivemychildFirstAid.IalsoherebyauthorizetheChildren’sLearningCenteratMitchellCollegepersonneltocallanemergencyambulance(attheparent/guardian(s)expense)ineventofaccidentoracuteillness,andtoarrangefornecessaryandemergencycaresuchasx-ray,examinations,anesthetic,medical,orsurgicaldiagnosisortreatment,andhospitalcare,toberenderedtotheminorunderthegeneralstatuteofspecialsupervision,andontheadviceofanyphysicianorsurgicallicensedtopracticeintheStateofConnecticutwhentheneedforsuchtreatmentisimmediate,andwheneffortstocontactme(us)areunsuccessful.Itisunderstoodthatconscientiouseffortwillbemadetonotifyme(us)beforesuchactionwillbetaken.IherebyabsolvetheChildren’sLearningCenteratMitchellCollegeandMitchellCollegeofanyandallliabilityclaims,coursesofaction,orexpenses,includinganyattorneyfees,andanyandallmedicalexpenses.IunderstandthatIamresponsibleforprovidingrevisionstotheinformationprovidedontheemergencyinformationformasneeded.Initial_________

Parentsignature:_______________________________________________Date:____________________

ParentSignature:_______________________________________________Date:____________________


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