Abide in the Vine Child Care Center
Application for Enrollment
Infants
[INFANT – REQUIRED FORMS]
Application for Enrollment INFANT – REQUIRED FORMS
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OUR VISION
To minister Christ’s love to the children and families of Owego and the surrounding areas by
providing a safe and loving environment where working parents may leave their children.
OUR PHILOSOPHY
We believe that all children are gifts from God. We recognize that the parents are the first and
best teachers of a child. We believe that the parents are entrusting to our care their most prized
blessings. We promise to tenderly guard and protect the children in our care.
We believe that God has given all children the ability to learn. We recognize that children
should be nurtured in the areas of physical, social, emotional and intellectual development. We
promise to provide experiences to encourage all areas of the child’s development.
We believe that God has given all children areas of special blessings. We recognize that each
child is unique in his or her gifts and abilities. We promise to search out and encourage each
child’s strengths.
We believe that God loves all his children. We recognize that all children need to feel love and
acceptance, encouragement and success. We promise to interact with your children with love,
joy, peace, patience, kindness, goodness, faithfulness, gentleness, and self-control.
We will start the day with a prayer, say grace at mealtimes, read Bible stories, sing Bible songs,
and say prayers at bedtime.
________________________________ _______________________ Parent’s Signature Date
RESERVING YOUR SPACE AT AVCCC: Please sign and return to AVCCC, 1277 Taylor Road, Owego, NY 13827
I wish to reserve an advance place for my child at AVCCC. I understand that
this requires the $25.00 one time registration fee plus one week tuition. I
further understand that this payment will reserve my child’s place for one
week only and that this fee is nonrefundable.
Signature: _______________________________________________ Date: ______________
Application for Enrollment INFANT – REQUIRED FORMS
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Abide in the Vine Child Care Center 1277 Taylor Rd., Owego, NY 13827
Registration Form
Child’s Name ____________________________________ Birthdate ______________________
Sex ________ Place of Birth _______________________ Nationality ____________________
Address ________________________________________ Telephone _____________________
Name of Mother or Guardian ____________________________ Age ____________________
Occupation _____________________________________ Work Phone ___________________
Name of Father or Guardian _____________________________ Age ____________________
Occupation _____________________________________ Work Phone ___________________
Marital Status of Parents _________________________________________________________
Custody-Visiting Arrangements ___________________________________________________
If child is adopted, list age at adoption ______________________________________________
Is child aware of adoption? _______________________________________________________
Emergency Information
Persons Authorized to Pick Up Your Child:
Name __________________________________________ Relationship _________________
Name __________________________________________ Relationship _________________
Name __________________________________________ Relationship _________________
Name __________________________________________ Relationship _________________
Persons to be Notified in Case of Emergency:
Name ________________________________________________ Phone _________________
Name ________________________________________________ Phone _________________
Name ________________________________________________ Phone _________________
Child’s Physician ______________________________________________________________
Address _____________________________________________________________________
Emergency Hospital Preference ___________________________________________________
______________________ ______________________________
Date Parent Signature
For Staff Reference: Check those of file:
Immunization Record _________ Physical Examination _________ Birth Certificate _________
Application for Enrollment INFANT – REQUIRED FORMS
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Application for Enrollment INFANT – REQUIRED FORMS
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Abide in the Vine Child Care Center Emergency Care
Child’s Full Name: ___________________________________________________________________
Child’s Home Address: _______________________________________________________________
Birthdate: ________________ Name of Person applying for Child: ____________________________
Please check one: □ Parent □ Caregiver □ Other □ Guardian
Mother’s (or Caregiver) Phone Numbers:
Home: ____________________ Work: ____________________ Cell: ____________________
Father’s Phone Numbers:
Home: ____________________ Work: ____________________ Cell: ____________________
Emergency Contact Persons: (people who you designated to pick up your child)
Relationship Contact Name Phone Number Cell Phone
1. _________________ _________________ _________________ _________________
2. _________________ _________________ _________________ _________________
3. _________________ _________________ _________________ _________________
4. _________________ _________________ _________________ _________________
Child’s Source of Medical Care/Primary Care Physician’s Name: _______________________________
Physician’s Phone Number ____________________________________________
Name of Medical Care Facility/Hospital: __________________________________________________
Does your child have any allergies? Yes? _________ No? ___________
If yes, please record allergies and any special needs:
In case of accident or injury, I authorize any and all emergency medical, dental, and for surgical care and
hospitalization advised by the physicians, surgeon, or hospital necessary for the proper health and well-
being of my child; including transportation for such services.
Yes ________________ No __________________
Please Sign _________________________________________________ Date ___________________
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(Note: Not all medical facilities will accept this form: some hospitals/doctors require that their own release be completed. And if a parent or legal guardian cannot be contacted personaily some hospitals will not treat a minor, even with a consent form, unless the problem is considered life-threatening. Check the policy in the area where your child would be treated.)
CONSENT FOR EMERGENCY MEDICAL CARE I,____________________________________________________________________________________ ( )Mother ( )Father ( )Legal Guardian
hereby give my consent to_______________________________________________________________ (Caregiver/Day Care Center)
who will be caring for my child___________________________________________________________ (Child’s Name) (Birth Date) for the period ________________________ to ______________________________ to arrange for emergency medical/surgical/dental care and treatment (including diagnostic procedures) necessary to preserve the health of my child. I acknowledge that I am responsible for all reasonable charges in connection with any care and treatment rendered.
Print Name: ______________________________
Pediatrician: ______________________________
Home Address: ___________________________ ________________________________________
Address: _________________________________ _________________________________________
Home Telephone: _________________________
Telephone: _______________________________
Business Telephone: _______________________ Name & Address of Primary Health Insurance Carrier: __________________________________ _________________________________________
Child’s Allergies, If any: _____________________ _________________________________________ Chronic Illnesses, If any: ____________________ _________________________________________
Group Number: ___________________________ Agreement Number: _______________________
Medicines Child is Taking: ___________________ _________________________________________
Signature: ___________________________________________________________________________ (Mother, Father or Legal Guardian) (Date) IN CASE OF AN EMERGENCY I CAN BE REACHED AT: (phone number) ________________________
Application for Enrollment INFANT – REQUIRED FORMS
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Application for Enrollment INFANT – REQUIRED FORMS
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Application for Enrollment INFANT – REQUIRED FORMS
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IMMUNIZATION POLICY
The Bureau of Communicable Disease Control of the New York State Department of Health has
legal authority to ensure that schools throughout the state comply with Section 2164(7)(a) of the
Public Health Law related to immunization requirements for school entry. Public Health Law
Section 2164(7)(a) requires that:
No principal, teacher, owner or person in charge of a school shall permit any child to be admitted to such
school, or to attend such school, in excess of fourteen days, without the certificate provided for in
subdivision five of this section or some other acceptable evidence of the child's immunization against
poliomyelitis, mumps, measles, diphtheria, rubella, varicella, hepatitis B and, where applicable,
Haemophilus influenzae type b (Hib); provided, however, such fourteen day period may be extended to not
more than thirty days for an individual student by the appropriate principal, teacher, owner or other
person in charge where such student is transferring from out-of-state or from another country and can
show a good faith effort to get the necessary certification or other evidence of immunization.
Abide in the Vine Child Care Center is considered a “school” and must uphold the above
mentioned Public Health Law. As a parent I will abide by the following Immunization Policy:
1. All immunizations MUST be kept current. Copies of updated immunization records will be given to the
AVCCC office after every vaccination. The immunization record must be an official document from a
health care provider indicating the immunizations given and the dates of administration.
2. If I fail to keep my child(ren) up to date with their immunizations – they will not be allowed to attend
AVCCC.
3. AVCCC will send out 3 reminders per year for updated immunization records… once in January, May, and
September.
4. A child may be exempt from one or more of the required immunizations for medical or religious reasons.
a. A medical exemption is given when a valid contraindication to vaccination exists. The medical
exemption must be certified by a physician licensed to practice in the State of New York and must
specify which immunizations are contraindicated and why.
b. A religious exemption is a written and signed statement from the parent, parents or guardian of
such child, stating that the parent, parents or guardian objects to their child's immunization due to
sincere and genuine religious beliefs which prohibit the immunization of their child.
It is the right and responsibility of AVCCC to accept or reject a medical or religious exemption. If
accepted - I understand this leaves my child susceptible to illness and my child will need to be removed
from AVCCC for at least 21 days should any other child exhibit a disease that would have been covered by
an immunization.
________________________________ ______________________________
Parent Name Parent Signature
________________________________ ______________________________
Child’s Name Date
Received by: ________________________________ ____________________
Director’s Signature Date Rec’d
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TUITION AGREEMENT
By signing this agreement, I acknowledge and agree to the following
statements set forth by the Board of Directors of Abide in the Vine Child Care
Center:
1. Tuition is due when my child arrives at Abide in the Vine Child Care Center
on the first day of attendance each week.
2. I understand that tuition is due even in the case of absences (illness,
vacation, time off of work, and our six vacation days).
3. I understand that if my child’s hours of attendance change, my tuition may
also change.
4. I understand that the fee schedule may change over time, and I agree to pay
my child’s tuition based on the current fee schedule approved by the Board
of Directors.
5. I understand that delinquent tuition could lead to the removal of my child
from the program. If an account becomes more than two weeks delinquent,
the child will not be permitted to attend. The position will be forfeited to
another client.
6. Non-Payment of Tuition could lead to collection or legal activity to recover
monies owed.
7. Two week written notice must be given before withdrawing the child from
the program. Failure to do so will require a two week payment.
________________________________ ______________________________
Parent Name Parent Signature
________________________________ ______________________________
Child’s Name Date
Received by: ________________________________ ____________________
Director’s Signature Date Rec’d
Application for Enrollment INFANT – REQUIRED FORMS
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PHOTO CONSENT I DO / I DO NOT give permission for my child ____________________________ (Child’s Name)
to be photographed while attending Abide in the Vine Chile Care Center. I understand that such
photographs may be included in displays both in the classroom, as well as other areas within the
Center.
I DO / I DO NOT give permission for my child’s picture to appear in promotional material
distributed by Abide in the Vine Child Care Center.
_____________________ ___________ _____________________ ___________
Parent’s Signature Date Parent’s Signature Date
Topical Over-the-Counter Ointments | Parental Authorization
I, ___________________________ (Parent/Guardian), give permission to the staff of Abide in
the Vine Child Care Center to administer the following over-the-counter ointments in their
original containers to my child ____________________(Child’s Name).
Diaper Cream: □ Yes □ No _______________________________________ (Brand Name)
Special Instructions: ____________________________________________________
Teething Gel: □ Yes □ No _______________________________________ (Brand Name)
Special Instructions: ____________________________________________________
Sunscreen: □ Yes □ No _______________________________________ (Brand Name)
Special Instructions: ____________________________________________________
Insect Repellant: □ Yes □ No _______________________________________ (Brand Name)
Special Instructions: ____________________________________________________
Other (Specify): □ Yes □ No _______________________________________ (Brand Name)
Special Instructions: ____________________________________________________
I am hereby verifying that these products have been previously applied to my child with no
allergic reactions noted and that I do not hold Abide in the Vine Child Care Center or its staff
responsible for any such reaction if it does occur.
_____________________ ___________ _____________________ ___________
Parent’s Signature Date Parent’s Signature Date
These products must be in a correctly labeled original bottle or container with your child’s first and last
name. Please give it to your child’s teacher. DO NOT STORE IN YOUR CHILD’S BAG.
Application for Enrollment INFANT – REQUIRED FORMS
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Abide in the Vine Child Care Center Emergency Notification Opt-In/Out Form
IN THE EVENT OF AN EMERGENCY: Abide in the Vine Child Care Center utilizes
multiple resources to alert our parents and staff of emergencies and closings. In the event of an
emergency or closing we utilize WBNG TV (Binghamton Channel 12) which includes
www.wbng.com. We have an emergency information phone line, 699-1511, which provides a
recording of up to date information. We also use a service that will send out automated phone
calls and/or text message alerts in the event of an emergency or closing. You may opt-in or out
of receiving automated calls by using this form.
OPT-IN/SUBSCRIBE TO AUTOMATED PHONE CALLS
I affirm that I am authorized to act on behalf of the following phone number(s) and request they
be added to receive automated phone calls in the event of an emergency or closing at Abide in
the Vine Child Care Center:
Phone #1 __________________________ Phone #2 __________________________
Phone #3 __________________________ Phone #4 __________________________
By signing below I hereby agree to opt-in/subscribe to receive automated emergency notification
calls to the above phone number(s) from Abide in the Vine Child Care Center... I understand
that I will only receive an automated call in the case of an emergency or closing at Abide in the
Vine Child Care Center. I understand it is my responsibility to keep my phone numbers up to
date and that I can opt-out/unsubscribe at any time by notifying the office. (Note: To sign up
for TEXT Alerts – you MUST follow the steps below under Texting Notification section
below).
Signature ____________________________________ Date ___________________
OPT-OUT/UNSUBSCRIBE FROM AUTOMATED PHONE CALLS
By signing below I hereby opt-out/unsubscribe from receiving automated emergency notification
calls from Abide in the Vine Child Care Center. I do NOT want to receive automated phone
calls. I prefer to receive a personal phone call.
Signature ____________________________________ Date ___________________
TEXTING NOTIFICATIONS
Abide in the Vine Child Care Center also offers a text alert subscription service. You may
automatically opt-in/subscribe to receive text alerts on your cell phone by texting
"AVCCC" to 80123 on your mobile phone. You can opt-out/unsubscribe at any time by
texting "STOP" to 80123. Our emergency alert text service is free. However, standard text
messaging fees from your wireless carrier may apply. Please check with your mobile phone
carrier if you aren't sure what fees apply when you send and receive text messages.
Application for Enrollment INFANT – REQUIRED FORMS
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Abide in the Vine Child Care Center 1277 Taylor Rd., Owego, NY 13827
Helpful Information for Teachers
Child’s Name _______________________________ Birthday _____________
List siblings and their ages ________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Are there other members of the household? If so, list name, age, and relationship:
______________________________________________________________________________
______________________________________________________________________________
Does your child nap? ___________________ When? _______________________
What time does your child go to bed at night? _______________ Wake up? _______________
Does your child have any special fears? _____________________________________________
_____________________________________________________________________________
Does your child have any problems with vision or hearing? □ Yes □ No
If so, please explain _____________________________________________________________
Does your child have any health problems that we should be aware of? □ Yes □ No
If so, please explain _____________________________________________________________
_____________________________________________________________________________
Are there any foods or drinks that your child should not have? □ Yes □ No
If so, please explain _____________________________________________________________
What does your child usually eat for breakfast? _______________________________________
_____________________________________________________________________________
Do you have any concerns about any aspect of your child’s development? □ Yes □ No
If so, please explain _____________________________________________________________
______________________________________________________________________________
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Age at which your child:
Crawled on hands and knees_________ Sat alone _________ Walked _________
Named simple objects _________ Slept through the night _________
Is any language other than English used in the home? □ Yes □ No
If so, please describe ___________________________________________________________
List illnesses your child has had __________________________________________________
____________________________________________________________________________
Does your child have frequent colds? □ Yes □ No Earaches? □ Yes □ No
Sore throats? □ Yes □ No Stomachaches? □ Yes □ No Fevers? □ Yes □ No
Has your child had any serious accidents or operations? □ Yes □ No
If so, please describe ____________________________________________________________
_____________________________________________________________________________
Does your child have any allergies? □ Yes □ No
If so, please describe ____________________________________________________________
Does your child take any regular medication? □ Yes □ No
If so, please describe ____________________________________________________________
When was your child last to a doctor? ____________________ Dentist? ___________________
Are there any special medical, physical, or emotional needs that the school or staff should be
aware of? □ Yes □ No If so, please describe ___________________________________
______________________________________________________________________________
How much television does your child generally watch every day? _________________________
What are your child’s favorite activities? ____________________________________________
_____________________________________________________________________________
What does your child enjoy doing with mother? ______________________________________
_____________________________________________________________________________
What does your child enjoy doing with father? _______________________________________
_____________________________________________________________________________
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Does your child play well alone? □ Yes □ No In groups? □ Yes □ No
Are there neighborhood playmates? □ Yes □ No
If so, with what age children does your child usually play? ______________________________
Does your child accept correction easily? ____________________________________________
What is the method of behavior control used in your home? _____________________________
_____________________________________________________________________________
Please circle items below that describe your child:
Happy Aggressive Friendly Moody Clumsy Dependent
Stubborn Impulsive Fearful Quiet Good-natured Even-tempered
Attentive Sympathetic Shy Sleepy Other:_________________________
Has your child learned to:
Listen to stories? □ Yes □ No Recognize and name common objects? □ Yes □ No
Follow simple directions? □ Yes □ No Throw and catch a ball? □ Yes □ No
Other? (Please note additional significant accomplishments) _____________________________
_____________________________________________________________________________
Has your child had group play experience? □ Yes □ No
Has your child been cared for by someone besides the family? □ Yes □ No
If so, please describe ____________________________________________________________
_____________________________________________________________________________
Has your child gone to preschool or daycare before? □ Yes □ No
Please describe previous experiences _______________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
What do you hope will be included in your child’s preschool program?
______________________________________________________________________________
______________________________________________________________________________
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How often does your baby take a bottle? ____________________________________________
Do you warm your baby’s bottle? _________________________________________________
After how many ounces do you usually burp your baby? _______________________________
How many ounces does your baby take at one feeding? ________________________________
If your baby is on a strict schedule, do you wake him/her to eat? _________________________
If your baby no longer takes bottles and is on table food, please list the foods your baby will not
eat – and if you prepare/serve certain foods a specific way (ex: sandwich broken into small
pieces or cut in half…): _________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Does your baby enjoy tummy time and/or playing on the floor? __________________________
Does your baby like to swing? ____________________________________________________
What do you do to put your baby to sleep? (ex: rocking, walking, falls asleep on his/her own in
crib…): _____________________________________________________________________
Is there anything else you would like us to know?
_____________________________________________________________________________
_____________________________________________________________________________
We request that at least one change of clothes be sent with your child each day. Please be
sure to have all your child’s items labeled with his/her name.
If you have any special instructions for your child’s care, please write them out for us to
have on file. We request to be informed of anything that may affect your baby’s day (ex:
having shots the day or two before coming in, not sleeping well the night before, not feeling
well, etc.).
Please feel free to talk to us about your baby’s care and to express any concerns that you
may have. We look forward to caring for your baby and watching him/her grow, along
with you.
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AVCCC Parent Permission Slip for the different stages of Infant Feeding
Please fill in the blanks…
Child’s Name: _____________________________________ Date: _________________
My child may only have: (Check all that apply)
________ formula
________ breast milk
________ baby food
________ food
________ cafeteria food
**IMPORTANT: It is recommended by the state for the parent to bring bottles already
made. However, if you prefer for us to make your baby’s bottles, we need written permission
and a feeding schedule. If you would like us to make your baby’s bottles, please fill in the
blanks below.
I, __________________________ (Parent/Guardian), give my permission to the staff at
AVCCC to mix (name of formula) __________________________ according to the
directions on the container. (If you mix it differently than on the container please write your
directions in the following space provided).
We are a breastfeeding friendly center. A special room is provided for your privacy and
convenience… Please indicate below whether you plan to breastfeed your child.
I, __________________________ (Parent) plan to breastfeed my child only. □ Yes □ No
PARENT’S SIGNATURE: ____________________________________
It is a choking hazard for children under the age of two to eat hot
dogs or grapes.
Application for Enrollment INFANT – REQUIRED FORMS
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Application for Enrollment INFANT – REQUIRED FORMS
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Abide in the Vine Child Care Center 1277 Taylor Road
Owego, NY 13827
607-687-2422
Dear Families at AVCCC,
In our efforts to provide your children with the best possible care, AVCCC
has established a hot lunch program in our center. This program will be available
to all students. We have designed a menu that is nutritious and well-balanced, and
has been reviewed and approved by a registered dietitian.
Due to the increased cost of the hot lunches, AVCCC is pursuing monetary
assistance through CACFP program (Children and Adult Care Food Program).
The application process takes approximately three months to complete, and
requires each of our attending families to fill out an income eligibility application
(attached).
Will you please fill out the attached application, place it in the envelope
provided, and return it to the tuition box? Your honesty and prompt fulfillment of
these applications is greatly appreciated, and confidentiality is guaranteed.
Thank you, as always for your continued support of our center. We are
excited to work with you to meet this important goal.
Always,
Mary Coveney
Food Service Director
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Understanding the CACFP Food Program Dear Parents,
Abide in the Vine Child Care Center is very proud of our food program. We are part of the Federal
government’s food program called CACFP. CACFP is an acronym for “Child and Adult Care Food
Program”. We would like to share some interesting facts with you concerning the CACFP program and
what this means for your baby as he/she eats here at AVCCC.
We would like to give you some information to help you decide if you want to take part in this
program for your baby. When a baby is enrolled into the center you will have to fill out a lot of paper
work to let us know important information. One of these papers is the CACFP Form.
Birth to 3 months:
When an infant is only on breast milk or formula that the parent provides your baby can still be on the
CACFP program. If you come to the center and breastfeed your baby then you cannot be on the
program.
4 months to 7 months:
Breakfast: Will be breast milk or formula
Lunch: Will be breast milk or formula and a veggie or fruit and cereal
Snack: Will be breast milk or formula
As the parent if you would like your baby to be fed baby food for breakfast just ask your baby’s
teacher and we will be glad to do that. All this is on the CACFP program.
8 months to 12 months:
Breakfast: Will be breast milk or formula and whole fruit with cereal.
Lunch: Will be breast milk or formula and a whole jar of veggies, ½ jar of Meat and ½ of jar of fruit.
Once you want your baby to start being introduced to baby food… all you have to do is tell your
teacher that your baby is ready for table food and we will provide Table food for your baby.
(Introduction to table food usually starts around 11 months and we only start with soft foods
combined with baby food)
Snack: Will be breast milk or formula or milk teething biscuits, arrowroot Cookies, or puffs.
12 months to 18 months:
Breakfast, Lunch and Snack: Will be whole milk and what the kitchen menu is serving.
If your child is having a hard time with table food after turning a year old, then the parent will need to
supply either baby food or table food the baby will eat. As the parent, if you bring in just baby food
we will still try our table food.
That is how the food program works. We will be happy to work with you has much as we can to
make the food program work for you and your baby.
There are ways to vary the eating pattern and still be part of the program. Please talk to your Baby’s
teacher when you have any questions or concerns about when or what your baby should be eating.
Thank you for allowing us here at Abide in the Vine Child Care Center to care and love your baby.
Application for Enrollment INFANT – REQUIRED FORMS
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Application for Enrollment INFANT – REQUIRED FORMS
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Application for Enrollment INFANT – REQUIRED FORMS
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Application for Enrollment INFANT – REQUIRED FORMS
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Application for Enrollment INFANT – REQUIRED FORMS
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Application for Enrollment INFANT – REQUIRED FORMS
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DSS Parents
Once your child has entered AVCCC it is your responsibility to make sure all costs are covered.
What this means is that if you decide to put your child into daycare before DSS accepts your
application you are responsible for the total cost until DSS approves you. Sometimes there is a
delay before DSS accepts you into their program. We encourage parents/guardians to make sure
all DSS is finalized before enrolling their children into our program.
My child (Child’s Name) ________________________________________ will attend AVCCC
on the following days:
□ Monday □ Tuesday □ Wednesday □ Thursday □ Friday
We accept children on a full time basis only. Full time care is based on our weekly rate for your
child’s age. This rate has to be met every week regardless if parents pay out of pocket or if it is
DSS subsidized. DSS does not cover days that your child does not attend. As a DSS recipient I
understand it is my responsibility to pay out of pocket for days my child does not attend
AVCCC.
Signature: ____________________________________ Date: _______________
Full Time Care
Here at AVCCC we have only have full time slots available. This statement is to make sure that
you understand that in the event that your child goes from full to part time we may remove them
from our program.
Full time care is based on our weekly rate for your child’s age. This rate has to be met every
week regardless if parents pay out of pocket or if it is DSS subsidized.
Signature: ____________________________________ Date: _______________
Parent Handbook
By signing below I acknowledge that I have received a copy of the AVCCC Parent Handbook
and understand its contents. I agree to abide by the AVCCC policies as set forth in the parent
handbook.
Signature: ____________________________________ Date: _______________