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Student’s Name Nickname DOB

Address

Home Phone Primary Language Spoken at Home

Allergies Start Date

PARENT/GUARDIAN INFORMATION

Parent/Guardian #1:

Name

Address

City, State, Zip

Cell Phone

Home Phone

Work PhoneEmail

Employed By

Work Address

Parent/Guardian #2:

Name

Address

City, State, Zip

Cell Phone

Home Phone

Work Phone

Email

Employed By

Work Address

CHILD’S PHYSICAL DESCRIPTION (REQUIRED BY LICENSING)

Eye Color Hair Color

Height Weight

Skin Color Race / Ethnicity

Identifying Marks

PARENT’S/GUARDIAN’S AUTHORIZATION OF OTHER PERSON(S) TO WHOM CHILD MAY BE RELEASED

I, _________________________, authorize the following individuals to pick up my child as needed. I understand that any

individuals not listed will not be allowed to pick up unless I provide written permission in advance. I understand that it is

my responsibility to keep this list of Authorized Persons up to date and will make all changes, additions, and deletions

in writing by updating this form.

Name Address

Telephone Number Relation to Child

Name Address

Telephone Number Relation to Child

Name Address

Telephone Number Relation to Child

Signature of Parent/Guardian:______________________________ Date: ___________________

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Child’s Name Date of Birth

I authorize the staff at The Children’s Workshop, who are trained in the basics of first aid and CPR, to give my child first aid

and CPR when appropriate.

I understand that every effort will be made to contact me in the event of an emergency requiring medical attention for my

child. However, if I cannot be reached, I hereby authorize the program to transport my child to the nearest medical care

facility and /or to _______________, and to secure necessary treatment for my child.

Child’s Physician’s Name: ___________________ Physician’s Phone Number _____________

Physician’s Address: ___________________________________________________________

Child’s Allergies: _________________________ Chronic Health Conditions: ______________

Emergency Contacts (In order to be contacted)

Name Address

Telephone Number Relation to Child

Do you give permission for your child to be released to this person? Yes _________ No _________

Name Address

Telephone Number Relation to Child

Do you give permission for your child to be released to this person? Yes _________ No _________

Name Address

Telephone Number Relation to Child

Do you give permission for your child to be released to this person? Yes _________ No _________

Child's Health Insurance Coverage

Parent Name

Parent Name

Policy #

Primary Phone #

Secondary Phone #

Primary Phone #

Secondary Phone #

Parent/Guardian Signature:__________________________________________________ Date: _____________________

Child’s Name: Date of Birth:

This form must be completed prior to the child’s first day of enrollment and updated at least annually. Please be thorough when

filling out this form - the more information we have about your child, the more individualized education we can provide!

Person providing information: Relationship to Child:

Please list all people in your child’s immediate family:

Name Relationship to Child Age Living in the house?

Please list all other non-family members who live in the household:

Name Relationship to Child/Family Age Length of time in household?

Language(s) spoken at home (please circle primary language):

Please list all locations (city, state) that your child has lived:

1. Birthplace: Age at time of move:

2. Age at time of move:

3. Age at time of move:

Are custodial parents of child currently (please circle): married separated divorced never married

If separated or divorced, please describe the legal custody arrangement:

*court documents must be provided for us to honor a custody agreement*

If separated or divorced, how do you feel the child has adjusted to the separation/divorce?

Are there other adults who have a significant part in raising your child? (please circle) YES NO

If yes, please indicate name, relationship & how child refers to this person (step-parent, grandparent,

boy/girlfriend, etc.):

Have there been any significant changes in the home over the last few years (such as: new marriages, deaths, births, address

changes, family separations/divorce, parent job change, death of a pet, etc.) that you believe have affected your child’s

development or behavior? (please circle) YES NO

If yes, please describe:

Signature of Parent/Guardian: __________________________________Date:____________

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Child’s Name: Date of Birth:

What do you feel are your child’s:

Greatest strengths:

Personality characteristics:

Areas of concern:

Will this be your child’s first experience in group child care (circle one): YES NO

If yes, please provide any information you think will be useful in helping your child feel comfortable at school:

If no, please describe prior child care experience (location, length of time, how did your child adjust, etc.):

Circle the state of your child’s current health: EXCELLENT GOOD FAIR POOR

Is your child currently taking any medication, including over the counter medications (please circle)? YES NO

If yes, please list medication, dosages, times and uses:

Has your child ever had any of the following?

Name of Condition Describe details, dates and/or age of onset

Serious Illnesses

Head Injuries

Seizures or convulsions

Surgeries/Hospitalizations

History of Ear Infections

Allergies

Asthma

Vision Problems or Hearing Problems

Known Complications at Birth

Frequent Nightmares and/or Sleep Concerns

Other

Signature of Parent/Guardian: __________________________________Date:____________

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Child’s Name: Date of Birth:

Please describe any other health information we need to know to care for your child:

Please indicate the age or range when your child could perform the following milestones (check ONE box per row):

Milestone 0-3

Months

4-6

Months

7-12

Months

13-18

Months

19-24

Months

2-3

Years

3-4

Years

Other

(specify age)

Not Yet

Applicable

Sit up without

help

Crawl

Pull up to stand

Walk Alone

Speak First

Word

Speak in

Sentences

Walk Up/

Down Stairs

Full Bladder

Control

Full Bowel

Control

Run

Jump in Place

Pedal a bike

Describe any speech difficulties your child has and/or any special words he/she uses to describe his/her needs:

Please describe any concerns you currently have or have had in the past about your child’s development or behavior:

What do you hope your child will gain from this early education experience:

Please describe what behavior management methods (if any) are used at home:

Signature of Parent/Guardian: __________________________________Date:____________

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Child’s Name: Date of Birth:

Please use the table below to indicate your child’s typical daily schedule:

Time of Day Description of activity, typical mood, meal, etc.

Infants/Toddlers: if your child still uses a bottle does he/she drink (circle one): FORMULA BREAST MILK BOTH

If your child drinks formula, please specify brand and any preparation details:

Is your child bottle fed (circle one): HELD IN LAP IN HIGH CHAIR BOTH

Does your child eat with (circle all that apply): SPOON FORK HANDS

Toddler/Preschool/Prekindergarten/School Age Children:

Child’s favorite foods:

Child’s refused foods:

Is there anything else we need to know about your child’s eating habits to properly care for him/her:

Signature of Parent/Guardian: __________________________________Date:____________

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Child’s Name: Date of Birth:

Children who have not yet toilet learned:

Type of diapers used (circle all that apply): DISPOSABLE CLOTH OTHER:

Does your child have frequent diaper rash (circle one): YES NO

Do you use (circle all that apply): LOTION POWDER OIL OTHER:

*please note, The Children’s Workshop cannot use powder in the classroom due to the danger of inhalation*

All children:

Are your child’s bowel movement regular (circle one): YES NO How many does he/she have per day:

Does your child have any problems with diarrhea, constipation, frequent urination or reluctance to use the bathroom

(circle one): YES NO

If yes, please describe:

Where does your child sleep (circle one)? BED CRIB OTHER:

Does your child become tired and/or nap during the day (include when and how long):

When does your child go to bed at night? And get up in the morning?

Describe any special sleep characteristics or needs (stuffed animal, story, mood on waking, etc.):

Does your child sleep in his/her own room (circle one): YES NO

If no, please note who shares the room:

Please note: The American Academy of Pediatrics has determined that placing a baby on his/her

back to sleep may reduce the risk of Sudden Infant Death Syndrome (SIDS). SIDS is the sudden

and unexplained death of a baby under one year of age. If your infant does not usually sleep on

his/her back, please contact your pediatrician immediately to discuss best sleeping positions for

your baby.

At The Children’s Workshop we follow these required safe sleep practices as recommended by the

American Academy of Pediatrics. Infants up to twelve months of age will be placed for sleep in a

supine position (wholly on their back) for every nap or sleep time. Infants will be placed for sleep

in a safe sleep environment; which includes: a firm mattress covered by a tight-fitting sheet in a

safety-approved crib and no other items will be placed in the crib occupied by an infant except for

a pacifier. Infants may not sleep in a car seat, bouncy seat, infant seat, swing, or any other type of

furniture/equipment that is not a safety-approved crib. Soft or loose bedding will be kept out of

sleep environments. These include, but are not limited to: pillows, sleep positioning devices,

blankets, bibs, etc. Infants will not be swaddled, but rather parent provided one-piece sleepers may

be used.

Signature of Parent/Guardian: __________________________________Date:____________

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In order to help us better serve the needs of all our families and children, we ask that you share with us any

information that will assist us in providing the best possible care for your child. If you feel comfortable, please

share the following information with us:

1) Has your child/children ever been involved with any community agencies or programs, if so please list or

check the agency that applies to your family:

___ Early Intervention (EI)

___ Occupational Therapy (OT)

___ Physical Therapy (PT)

___ Speech Therapy (ST)

___ Home Based Services

___ Child Outreach

___ Family Care Community Partnerships (FCCPs)

___ CEDARR Programs (Comprehensive Evaluation Diagnosis

Assessment Referral Re-Evaluation)

___ Preschool Outreach Program

___ The Child and Family Counseling Center (CFCC)

___ Home for Little Wanderers – Family/Clinical Support

___ Safe at Home

___ Northern Rhode Island Collaborative (NRI)

___ Gateway Healthcare, Inc

___ Spurwink School

___ Katie Beckett Waiver

___ The Providence Center

___ Bradley Hospital

___ Butler Hospital

___ Meeting Street School

___ The Groden Network

___ Children’s, Friends, and Family Services

___ Children’s Community Support Collaborative

___ Counselor - please specify

______________________________________

___ Other - please specify

____________________________________

2) Has your child ever been diagnosed with any of the following: (if so please check of the areas that apply)

ADD (Attention Deficit Disorder) Developmental Delays

ADHD (Attention Deficit Hyperactivity Disorder) Sensory Integration

ODD (Oppositional Defiant Disorder) Depression

Autism Spectrum Disorder Anxiety

Asperger’s Disorder Other, please specify below

Is there anything else we should know?

___________________________________________________________________________________________________________________________

3) Does your child currently have an Individualized Education Program (IEP)? (please circle one) YES / NO

If yes, may we have a copy for our records? __________

4) Do you have any concerns regarding your child’s social and emotional wellbeing that you would like to bring to our

attention? If so please check any below that apply:

___ Difficulty responding to authority ___ Emotional outbursts / inability to control emotions

___ Aggression ___ Other, please specify____________________________________

Child’s Name: Date of Birth:

Parent/Guardian Signature :_______________________________________ Date: ____________________

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Child’s Name: _____________________________________________________ Start Date: __________________

In consideration, I/we, as parent(s) or guardian, enroll or reenter our child(ren) at The Children’s Workshop with

the understanding of the following:

In consideration of the enrollment of our child(ren) at The Children’s Workshop, I/we, for the said child, hereby

release The Children’s Workshop, its Officers, Directors, and Employees from all liability for injury to the child, in

excess of the amount payable under any insurance carried by The Children’s Workshop. I/we authorize any

physician selected by the center to hospitalize and/or secure proper medical care for the child in the event that

I/we cannot be contacted directly for permission in an emergency.

Any/All late departures, after closing time, are subject to a late fee as defined on your rate sheet. If you are

consistently late in picking up your child, you may be asked to secure other child care arrangements. It is

also understood that TCW does not provide transportation to/from home and parents/guardians are

required to drop-off and pick-up their child.

To secure a space for your child at The Children’s Workshop, a non-refundable registration fee and

prepaid tuition equal to first and last week’s tuition is required.

A registration fee will be charged upon initial enrollment and then annually thereafter.

Hours Attending:

Monday Tuesday Wednesday Thursday Friday

Please indicate which meals you would like your child to receive while in our care:

Monday Tuesday Wednesday Thursday Friday

Breakfast / AM Snack

Lunch

PM Snack

The tuition fee for child care services will be $___________ per week, based on __________ hours per week.

Reimbursement will not be made when your child(ren) is late, dismissed early or absent.

The tuition payment is due in accordance with the policy and tuition sheet. The company automatically adds a

$35.00 late fee for each week that you are late in making tuition payments. Accounts that are one (1) week in

arrears are subject to termination. A prepaid tuition equal to one week of tuition is due at the time of

enrollment.

There will be a $35.00 charge for returned checks.

Notice must be given when your child will be absent or late.

The Children’s Workshop reserves the right to raise rates at any time with a 2 week written notice.

To maintain proper staff/child ratio, agreed upon dates and times on the contract cannot be altered

unless changed at the office and another contract must be completed, signed, and dated.

Revised June 2017 BK

If any type of change in parent agreement is necessary, please contact the office as soon

as possible. Examples: Emergency person, address, telephone number, times, fees, medical

information, etc.

When The Children’s Workshop is closed for a holiday, the weekly tuition payment will remain the same.

Note: part-time enrollees, if your child is scheduled to attend on a holiday another day cannot be

substituted.

The Children's Workshop will endeavor not to close during inclement weather conditions. The center

will close only when a State of Emergency is declared or unforeseen circumstances arise at the child

care center. Tuition payments will remain the same.

Two weeks written notice is required prior to withdrawal of your child from The Children’s Workshop. If notice

of two weeks is not received, your account will automatically be billed for the two weeks. Termination

arrangements must be made with the Director and Assistant Director only.

Accounts one week in arrears will be given a written termination notice from the Director. If payment is not

received by the end of the following business day, or if special arrangements have not been made, child

care services will be terminated and parent/guardian may be subjected to litigation for any monies owed.

Parent/guardian acknowledges and agrees that they shall be responsible for any and all costs of collection,

including, but not limited, to reasonable attorney fees.

The Children’s Workshop provides a happy, healthy, educational environment for your children and hopes to

meet your expectations. If you have any questions, or special needs for the care of your children, please feel

free to discuss these concerns with the Director at your convenience.

Family Handbook: The Children’s Workshop Family Handbook is available on our website at:

http://www.childrensworkshop.com/tcw-forms-information. Hard copies may be requested from your Center

Director as well. Please read and review it thoroughly prior to completing this Enrollment Packet

I certify that I have read and understand the information contained in the Family Handbook, the Policy

and Tuition Sheets, and this Enrollment contract, and agree to the terms and conditions set forth

therein.

_________________________________________________________________ _____________________

Parent/Guardian Signature Date

_________________________________________________________________ _____________________

Director’s Signature Date

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Child’s Name Classroom

I, _____________________________, give the staff at The Children’s Workshop permission to use

Parent’s Name

__________________________ on my child for diaper rash or other skin condition.

Product Name

I have used this product previously without any adverse reaction to my child’s skin.

Instructions from Parent Regarding Application/Notes:

______________________________________ ___________________

Parent’s Signature Date

******A SEPARATE FORM MUST BE FILLED OUT FOR EACH CHILD****

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Please read the information below, select YES or NO, and initial your acceptance to the right of each. Please sign at the bottom of

the page to acknowledge that you have received, read and accepted these policies and grant permission as stated in each box.

Child’s Name: _______________________________________________________________________________________

Permission for Media Sharing & Exposure

At The Children’s Workshop we endeavor to send our families regular and meaningful communication so they can feel confident

that their child is learning and thriving while at school! This communication comes in the form of pictures, videos, and written

documentation. We also use media such as images and video to document a child’s growth and development, for both progress

reports and child assessment purposes and also for our continuous internal program improvement efforts. From time to time, we

have opportunities to share images and videos of the great things happening at our schools with the outside world as well. We may

want to use pictures of children enrolled at The Children’s Workshop on our website for our families to view, allow newspapers or

other media outlets to film/photograph the events in our programs, or share exciting accomplishments on our social media sites. In

all cases, pictures and/or videos are for internal or promotional use only and will never be shared beyond these uses or without

express parental consent. By signing your consent to allow TCW to use images and video of your child you acknowledge your

understanding that neither you nor your child will receive remuneration for your voluntary participation or future use of any

photo(s) and/or images.

We consider our Media Sharing to fall into three categories – please let us know your preferences below for which your

child’s images may be used. You may change your preferences at any time simply by completing a new version of this

form.

Initial

1. Child Assessment / Program Use ONLY

I give permission for my child’s image to be used ONLY for private child

documentation purposes. These images shall never be posted publicly

at the school or otherwise, and will only be viewable to me (at my

request) and my child’s teachers and direct caregivers.

YES, my child may be photographed or filmed

for this purpose.

NO, my child may NOT be photographed or

filmed for this purpose.

_______

2. Internal TCW Community Communications

In addition to use for child assessment purposes (as defined above), I

also give permission for my child to be photographed or filmed for use

within the center, such as photos displayed on bulletin boards, for

family communications including newsletters to parents (paper and

digital including those sent through Kaymbu to private parent accounts)

and center only private Facebook Groups, and internal TCW

companywide newsletters (visible to TCW employees only). I

understand that these communications may be visible to visitors of our

program and that while TCW shall do everything in its power to control

the distribution of communications to current families only, they cannot

control how the media is used after it is sent (i.e. other families may

choose to share them beyond the initial distribution).

YES, my child may be photographed or filmed

for this purpose.

NO, my child may NOT be photographed or

filmed for this purpose.

- If YES -Please indicate your preferred method of

contact for Kaymbu Communications:

Parent #1: Name: ____________________

Email Text Message

Parent #2: Name: ____________________

Email Text Message

_______

3. Media / External Communications

In addition to use for child assessment and internal TCW community

communications (as defined above), I also give permission for my child

to be photographed or filmed for media use and publicity in

conjunction with The Children’s Workshop. This may include use on

the Children’s Workshop external website and social media sites

(including Facebook, Twitter, Pinterest, YouTube and others) and from

time to time use for promotional and advertising campaigns which may

include television, radio, billboards, print and digital media, etc.

YES, my child may be photographed or filmed

for this purpose.

NO, my child may NOT be photographed or

filmed for this purpose.

_______

Parent/Guardian Signature________________________________________________________ Date______________

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Child’s Name: _______________________________________________________________________________________________

My Child will arrive at the program by: My Child will depart from the program by:

_____ Unsupervised Walk _____ Unsupervised Walk

_____ Supervised Walk (who ____________) _____ Supervised Walk (who ____________)

_____ School Bus Drop Off _____ School Bus Pick Up

_____ Program Bus _____ Program Bus

_____ Program Van _____ Program Van

_____ Parent Drop Off _____ Parent Pick up

_____ Other (describe__________________) _____ Other (describe__________________)

___________________________________________________________________ ___________________

Parent/Guardian Signature Date

PLEASE ENSURE THAT YOU HAVE ALSO COMPLETED THE “AUTHORIZATION OF OTHER PERSONS CHILD MAY BE

RELEASED TO” SECTION ON THE REGISTRATION FORM.

I , give permission to The Children’s Workshop to transport my child

Parent/Guardian Name

________________________________________________, to or from ______________________________________________

Child’s Name Location or Name of School

on a van owned or leased by The Children’s Workshop. I also give permission for my child to be transported in the van for:

Before school

After school

I/ we, for the said child, hereby release The Children’s Workshop, its Officers, Directors and employees from all liability for

injury to the child, excess of the amount payable under any insurance carried by The Children’s Workshop.

______________________________________________________________________ ___________________

Parent/Guardian Signature Date

The Role of Child Care Health Consultants

Child Care Health Consultants are licensed health professionals with education and experience in community health and

child care. Child Care Health Consultants and child care staff work together to promote healthy and safe environments for

children. Through onsite and telephone consultation, health education, and technical assistance, Child Care Health

Consultants work with individual child care facilities to help create environments that best support the healthy growth and

development of young children.

Child Care Health Consultants:

assess the health and safety needs and practices in the child care facility,

review safe medication administration practices,

develop strategies for inclusion of children with special care needs,

establish and review health policies and procedures,

manage and prevent injuries and infectious diseases,

connect families with community health resources, and

provide health education for staff members, families and children.

Please note that Child Care Health Consultants are not direct care providers and should not be considered part of your

child’s direct care team. The Children’s Workshop employs a team of Child Care Health Consultants to assist all of our

schools; Health Consultants are not on premises at every school 100% of the time, nor should their advice or information

they share be relied upon solely – parents should always consult their child’s pediatrician or health care professional.

I acknowledge that I have received, read, and understand this information and I understand the role of

the Child Care Health Consultant at The Children’s Workshop. I hereby give permission for the Child

Care Health Consultants employed by The Children’s Workshop to access my child’s file including

immunization records, physical exam, and medication administration information.

Child’s Name____________________________________ Guardian Initial____________

Release of Information

I _______________________give my permission to ___________________, at Parent’s Name Pediatrician or Practice Name

(____)__________ to release the following to The Children’s Workshop for patient Phone Number

_______________________. Childs Name

Immunization Record _X_ Verbal Communication _X_

Lead Level _X_ Yearly Physical _X_

Medication Instructions _X_ Other X_

Signature: __________________________________ Date: _____________