REGISTRATION - Pyramid Learning Academy

Child Application Form

This section is to completed by the Child’s guardian or parents.

Child's Full Name

Nickname

Date Of Birth

Address

Parent(s)/Guardian(s) Information

Father's Full Name

Address

Mother's Full Name

Address

Father's Employer

Employer's Address

Employer's Telephone

Mother's Employer

Employer's Address

Employer's Telephone

Emergency Contact Person

Alternate Contact 1

Alternate Contact 2

Alternate Contact 3

Instructions Regarding How Parent/Guardian May Be Reached In An Emergency

Person(s) To Be Contacted In An Emergency Ff Parent(s)/Guardian(s) Cannot Be Reached:

Emergency Contact 1

Emergency Contact 1-Address and Telephone

Emergency Contact 2

Emergency Contact 2-Address and Telephone

Emergency Contact 3

Emergency Contact 3-Address and Telephone

Doctor's Information

Doctor's Name

Address

Telephone Number

EMERGENCY AUTHORIZATION: I give permission for the child care facility to obtain emergency medical treatment, including emergency transportation, for my child if I cannot be reached immediately. I agree to be responsible for an emergency medical expenses incurred. (If parent/guardian refuses to sign, instructions must be attached stating what procedure the facility is to follow in an emergency)

Do you agree with the Emergency Authorization Agreement?

Yes Please State Below What Procedure The Facility Is To Follow In An Emergency If You Refuse To Agree.

Child’s Pre-Admission Record (Continued)

Describe The Special Needs Or Instructions

PERSON(s) THE CHILD MAY BE RELEASED TO: In agreement stating: "I understand that the Department of Human Resources does not inspect activities away from the child care facility (home or center). The licensee of the child care facility assumes full responsibility from such activities.

Person A Full Name

Person A - Relationship To Child

Person A -Address

Person A -Telephone

Person B Full Name

Person B - Relationship To Child

Person B -Address

Person B -Telephone

Person C - Relationship To Child

Person C -Address

Person C -Telephone

CHILD PARTICIPATION AGREEMENT

I give permission for my child to participate in activities away from the facility

Yes No

I give permission for my child to participate in transportation provided by the facility

Yes No

I give permission for my child to participate in water activities provided by the facility

Yes No

Child's Personal Data

Full Name

Date Of Enrollment

Weekly Schedule: (Note: The weekly schedule is intended to represent a typical week and will only be used to assist with teacher scheduling. We realize that actual schedules will vary based on your needs.)

Monday

Tuesday

Wednesday

Thursday

Friday

MEDICAL INFORMATION Please state NONE if the question is not applicable to your child.

Child's Dentist - Full Name

Child's Dentist - Contact Number

Child's Dentist - Address

Child Insurance Coverage

No Yes (Please state the Insurance Company below)

Child's Hospital Preference

Any allergies? *(If your child cannot be served the CACFP meal pattern, a statement from the child’s health provider must be completed.) Please be as thorough as possible.

Any condition or fears?That may require special care, procedures, services, medication or diet.

Any disabilities? A physical, mental or developmental disability that would prevent my child from participating in the school’sregular program or activities.

PARENTS AGREEMENT

If your child has a temperature of 100 degrees or more, or any symptom of a contagious disease or infection, you must make other child care arrangements. In most cases, we ask that your child remain at home at least 24 hours after leaving the school because of an illness. Re-admittance is at the discretion of the Director. In addition, I agree to notify Pyramid Learning Academy with in 24 hours if any member of my immediate household is diagnosed with a communicable disease.

Yes

MEDICAL AUTHORIZATION - I agree that Pyramid Learning Academy staff may authorize the physician of their choice to provide emergency treatment in the event that neither I nor our family physician can be contacted immediately. Pyramid Learning Academy agrees to provide transportation to an appropriate medical resource in the event of an emergency and will not administer any drug or medication without specific instructions from the physician. In the event of such accident or illness, all medical expenses incurred are my responsibility. I release Pine Street Learning Academy, and all of its employees, officers, directors, servants, and agents from liability incurred as a result of any act they may perform on behalf of my child.

Yes

DELIVERY OF STUDENTS - I agree that when delivering my child to the school, I or the person I have authorized to drop off my child, will personally deliver my child to his/her teacher or the staff person in charge. I further agree that when picking up my child, I or the person I have designated, will personally come into the school and receive my child from his/her teacher or the staff person in charge. At no time will I leave my child at the school without first making his/her presence known to the staff, nor will I take my child from the school without notifying my child’s teacher. I further agree that I or the person I have authorized to deliver and/or pick up my child will sign my child in/out on a daily basis.

Yes

CHANGE OF STATUS - I agree to notify Pyramid Learning Academy immediately of any changes that occur in the information provided in this enrollment application including work and home address, phone numbers, physician’s name, living arrangements, health information, emergency contacts, etc.

Yes

ACTIVITIES OUTSIDE THE FENCED AREA OF THE FACILITY - I give my permission for my child to participate in activities planned outside the school’s fenced area.

I Do Agree I Do Not Agree

CHILD ABUSE/ NEGLECT - As a child care provider, Pyramid Learning Academy is mandated by state law to report any cases where there is reasonable cause to believe that a child has been neglected, exploited, deprived, sexually assaulted, sexually exploited, physically injured or suffered death by other than accidental means by a parent, guardian or caretaker, to the proper authorities. Pyramid Learning Academy will cooperate fully with the authorities in the investigation of all such cases. To avoid any misunderstandings, parents are encouraged to keep the school director aware of any unusual bruises, marks or injuries occurring in the home.

Yes

CONFIDENTIALITY STATEMENT - Information pertaining to your child is considered confidential and will not be released by Pyramid Learning Academy to third parties without first obtaining your written permission. However, it may be necessary to share relevant information relating to your child’s family situation, medical status and behavioral characteristics with authorized members of the state child care licensing agency or with persons authorized by the state licensing regulations or law to receive such information.

Yes

PARENTS RIGHT TO KNOW NOTICE * UNDER THE DELAWARE CODE, YOU ARE ENTITLED TO INSPECT THE ACTIVE RECORD AND COMPLAINT FILES OF ANY LICENSED CHILD CARE FACILITY. TO REVIEW A CHILD CARE FACILITY RECORD CONTACT: the administrative specialist, OFFICE OF CHILD CARE LICENSING, 3411 SILVERSIDE ROAD, CONCORD PLAZA ǀ HAGLEY BUILDING, WILMINGTON, DELAWARE 19810, phone (302) 892-5800. You may also view substantiated complaints and compliance review histories by visiting the Office of Child Care Licensing’s child care search at http://www.apex01.kids.delaware.gov:8081/occl/

Yes

PARENTS PERMISSION

SCREEN TIME PERMISSION * Children over the age of two may have an educational video, movie, or game incorporated into their curriculum. These may be viewed on a television, computer, tablet, or gaming device. These will be age-appropriate and limited to one hour per day unless a special occasion or activity occurs. Children will be closely supervised while using the internet.

Yes

PARENT PERMISSION TO SLEEP ON A MAT * Children, between the ages of 12 and 18 months will be transitioned from sleeping in a crib to a cot, mat, or bed when they are able to walk.

Yes

TRANSPORTATION PERMISSION * I hereby give permission for my child to be transported by --- Please list any special needs or problems which might require special attention during transportation and directions on how to handle the special need or problem. This information will be carried with the operator of the vehicle named above.

Program

Please Check One

I would like to complete the ASQ-3 (which looks at overall development) I would like to complete the ASQ:SE-2 (which looks more closely at social emotional development) I would like to complete BOTH ASQ Questionnaires

Please Check One

I would like to complete my requested questionnaires via a hard copy that will be mailed/given to me. The address given below is my mailing address. I would like Teacher to complete my child’s questionnaires