Calico Butterfly Preschool
CALICO BUTTERFLY PRESCHOOL HOME PAGE
REGISTRATION FORM: Calico Butterfly Preschool
Please be sure to complete information regarding your child. Family information that is the “same” may be so noted.
Personal, Family, and Other Information:
Child’s Name: Date of Birth: Sex:
Nicknames: Home Telephone:
Street Address: Mailing address:
City: State: Zip Code: City: State: Zip Code:
Mother or Guardian: Father or Guardian:
Street Address: Street Address:
City: State: Zip Code: City: State: Zip Code:
Mailing Address: Mailing Address:
City: State: Zip Code: City: State: Zip Code:
Home Phone: Cell/Page #: Home Phone: Cell/Page #:
Place of employment: Place of Employment:
Occupation: Occupation:
Street Address: Street Address:
City: State: Zip Code: City: State: Zip Code:
Work Hours: Work Phone: Work Hours: Work Phone:
Names, Ages and Grade Levels of Brothers and/or Sisters:
Schools, Groups, or Private Homes previously attended:
Church, if currently attending:
I hereby authorize the following person(s) to pick up my child:
Name: Relationship: Name: Relationship:
Address: Address:
Telephone: Alternate #: Telephone: Alternate #:
Signature: Signature:
Name: Relationship: Name: Relationship:
Address: Address:
Telephone: Alternate #: Telephone: Alternate #:
Signature: Signature:
The following person(s) may not remove my child from the center:
Name: Documentation: Y / N Name: Documentation: Y / N
Signature: Telephone:
Medical and Emergency Information:
In case of injury or sudden illness, will be called first. If medical care is necessary, call:
Doctor: Address: Phone:
Healthcare Provider: Address: Phone:
Hospital: Address: Phone:
Insurance Carrier: Policy Number: (Please provide copy.)
My child is allergic to these foods or other substances:
If an allergic reaction occurs follow these procedures:
My child has these
physical conditions: (heart trouble, foot
problem, hearing impairments, hernia, infection susceptibility,
convulsions, etc.):
Precautions and procedures to be taken:
Additional comments or other special instructions:
In the event of a medical emergency, I hereby give my consent
for Calico Butterfly Preschool to arrange for emergency
medical treatment necessary to preserve the health of my child and to any hospital or
doctor to render immediate care
and medical treatment, including diagnostic procedures and blood transfusions, by
authorized pre-hospital personnel
and members of the hospital staff, as may in their professional judgment be necessary or
in the best interest of my child’s
health and safety. I hereby acknowledge that
I will be responsible for all reasonable expenses in connection with the care
and treatment rendered.
Signature:
If I cannot be contacted in the event of an emergency, I hereby authorize the following person(s) to pick up my child:
Name: Relationship: Name: Relationship:
Address: Address:
Telephone: Alternate #: Telephone: Alternate #:
Signature: Signature:
Signature:
acknowledge
that all of the information provided on this Enrollment
Form is current and accurate. I hereby agree
to notify the school in writing if any of the information contained on this Enrollment
Form should change during the course of the school year in order that all information may
be current and accurate at all times.
I will not hold Calico Butterfly Preschool responsible I fail keep this information
current and accurate.
Signature:
Discipline & Guidance Policy and Acknowledgment: Calico Butterfly Preschool will only use positive guidance techniques that model and encourage age-appropriate behavior and self-discipline. When problems arise, staff members will facilitate opportunities to co-operate, help, negotiate, and communicate to solve the situation. When needed, children will be given a time to “sit out” for a short period (no more than 2 minutes after gaining control) at which time staff will interact with the child to understand the consequences of their behavior and before being redirected or allowed to participate again. Calico Butterfly Preschool will not tolerate any method of discipline that could cause physical, mental, or emotional, harm to your child including corporal punishment. Calico Butterfly Preschool will only communicate with the parents regarding inappropriate behavior problems when they are ongoing or of a serious nature that is either dangerous, or uncontrollable. Please note that Children’s Christian Preschool reserves the right to ask you to remove your child from our program(s) if it is determined that your child does not respond to discipline and continues to be disruptive to the class on a continual basis.
I hereby acknowledge that I have read and understand the policies and procedures with regards to discipline.
Signature:
1.Nursery/Toddler |
for these days each week: |
M |
T |
W |
Th |
F |
from |
2.AM Extended Care |
for these days each week: |
M |
T |
W |
Th |
F |
from |
3.P/T or F/T Preschool |
for these days each week: |
M |
T |
W |
Th |
F |
from |
4.PM Extended Care |
for these days each week: |
M |
T |
W |
Th |
F |
from |
I
understand that I need to make arrangements for my child to be admitted and released from
school on time as indicated above. If I
am going to be late by more than ten minutes, I agree to notify the school in a timely
manner and understand that there is a fee of
$1 for every five minutes after the first ten minutes that my child is late in being
picked up. If an alternative arrangement for the release of my child needs to be made, I
will use the following code word as
my telephone verification for authorization. Any
other person authorized to pick up my child will be required to show identification.
I
agree to pay the $75.00 registration fee that is non-refundable. I also agree to submit tuition as due based on the
price of $
per hour for a total of $
per year. Payment is due the first class day of each month
for (#) months
in the amount of
$
. I understand that I will be
responsible to pay for any additional services provided by Calico Butterfly Preschool
other than those stated above at the stated hourly rate.
There will be a $5.00 late fee for tuition submitted after the 5th of
the month. Calico Butterfly Preschool
reserves the right to withdraw your child when tuition remains unpaid. Please note that scholarship applications are
available. I agree to the enrollment of (child) in Calico Butterfly Preschool. We have read
and agree to comply with the policies and procedures of Calico Butterfly Preschool as
described above and in the Parent’s Handbook. We
agree to submit tuition as due unless other arrangements have been previously made with
the Direct of Calico Butterfly Preschool.
For CBP Only |
Review of Immunization Requirements: |
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DTP or DtaP: 4-dose series |
1st: |
2nd: |
3rd: |
4th: |
5th: after age 4 |
MMR: 1 dose |
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Polio: 3-dose series |
1st: |
2nd: |
3rd: |
4th dose recommended after age 4 |
2nd dose recommended 4-6 years of age |
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Hepatitis B: 3-dose series |
1st: |
2nd: |
3rd” |
Varicella: 1 dose |
Not required with history chickenpox disease |
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Hib: 3-dose series |
1st: |
2nd: |
3rd: |
Hepatitis A: 2 dose series recommended after age 2 |
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Signature: Enrollment Date:
The State of New Mexico requires your child to have all age-appropriate vaccinations to attend school. A current immunization record with a physician’s signature or a valid exemption document must accompany this Form.
Date of Enrollment:
Date of Disenrollment: