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Home › Child Enrollment Forms › Tree House Academy – FERNANDINA BEACH, FL

Tree House Academy – FERNANDINA BEACH, FL

1 Admission Information

2 Discipline & Guidance Policy

3 Parent Handbook Agreement

4 Media Consent & Release

5 Webcasting Consent & Release

6 Sunscreen Application

7 Insect Insect Repellent Application

8 Student Pick-up Policy

9 Illness Policy

10 Nut Free Policy

11 Screen Time Policy

Admission

Information

Location Name*
Child's Photo (Filetypes accepted are JPG & PNG. Maximum file size allowed is 2MB.)*
Accepted file types: jpg, gif, png.
Child's First Name*
Child's Last Name*
Child's Date of Birth*
Date Format: MM slash DD slash YYYY
Parent's or Gaurdian's Name*
Date of Admission*
Date Format: MM slash DD slash YYYY
Date of Withdrawal*
Date Format: MM slash DD slash YYYY
Child's Home Address*

List telephone numbers below where parents/guardian may be reached while child will be in care

Mother’s Phone Number*
Father’s Phone Number*
Guardian’s Phone Number*

Name, address & phone number of person to call in case of an emergency if parents/guardian cannot be reached*
Relationship*

Declaration of release
- I hereby authorize the childcare operation to allow my child to leave the childcare operation ONLY with the following persons. Please list name & telephone number for each. Childen will only be released to a parent or a person designated by the parent/guardian after verfication of ID.
extra numbers
Name of Person Phone Number

Check All That Apply

1.Transportation
I hereby*
- give
- do not give
my consent for my child to be transported and supervised by the operation’s employees.
Walk home*
- for emergency care
- on field trips
- to and from home
- to and from school
2.field trips
I hereby*
- give
- do not give
my consent for my child to participate in field trips.
Parent’s Comments*
3.water activities
I hereby*
- give
- do not give
my consent for my child to participate in the following water activities.
Water Activities*
- sprinkler play
- splashing/wading pools
- swimmimg pools
- water table play
4.RECEIPT OF WRITTEN OPERATIONAL POLICIES
Reciept of Facility*
- I acknowledge receipt of the facility’s operational policies including those for discipline and guidance.
5.i understand that the following meals will be served to my child while in care
meal_timing*
- None
- Breakfast
- AM Snack
- Lunch
- PM Snack
- Supper
- Evening Snack
6.my child NORMALLY in care ON THE FOLLOWING DAYS AND TIMES

monday
- Mondays
monday_from
monday_to
tuesdays
- Tuesdays
Tuesdays-from
Tuesdays-to
wednesdays
- Wednesdays
Wednesdays-from
Wednesdays-to
Thursdays
- Thursdays
Thursdays-from
Thursdays-to
Fridays
- Fridays
Fridays-from
Fridays-to
Saturdays
- Saturdays
Saturdays-from
Saturdays-to
sundays
- Sundays
sundays-from
sundays-to

AUTHORIZATION FOR EMERGENCY MEDICAL ATTENTION

Physician Name*
Phone Number*

Address*

Name of Emergency Medical Care Facility*
Phone Number*

Address*
agree_medical care*
- I give consent for the facility to secure any and all necessary emergency medical care for my child.
Signature - Parent or Legal Guardian*
List any special problems that your child may have, such as allergies, existing illness, previous serious illness, injuries and hospitalizations during the past 12 months , any medication prescribed for long-term continuous use, and any other information which caregiver’s should be aware of*
Child daycare operations are public accommodations under the americans with Disabilities Act (ADA), Title 111. if you believe that such an operation may be practicing discrimination in violation of Title 111, you may call the ADA Information Line at (800) 514 - 0301 (voice) or (800) 514 - 0383 (TTY).

Signature - Parent or Legal Guardian*
Date*
Date Format: MM slash DD slash YYYY

SCHOOL AGE CHILDREN
- My child attends the following school

Name of School
School Phone Number

School Address
CHECK ALL THAT APPLY
All of the apply
- His/Her immunizations and/or tuberculosis tests are current
- Vision and hearing screening records are on file
- My child has permission to ride a bus, and/or
- Walk to or from school or home,
- To be released to the care of his/her sibling under 18 years old (details provided below)

Sibling First Name
Sibling Last Name

IMMUNIZATION RECORD
immunizaton_record*
- I have provided the childcare operation with a copy of my child’s most current immunization record.
ADMISSION REQUIREMENT

If your child does not attend pre-kindergarten or school away from the child-care operation, one of the following must be presented when your child is admitted to the child-care operation or within one week of admission.
Please check only one option*
- A signed and dated copy of a health care professional’s statement is will be provided upon enrollment.
- Medical diagnosis and treatment conflict with the tenets and practices of a recognized religious organization, which I adhere to or am a member of, and will provide a signed and dated affidavit stating this upon enrollment.
- My child has been examined within the past year by a health care professional and is able to participate in the day care program.

Signature - Parent or Legal Guardian*
Date*
Date Format: MM slash DD slash YYYY

Discipline &

Guidance Policy

Discipline must be
- Individualized and consistent for each child
- Appropriate to the child’s level of understanding; and
- Directed toward teaching the child acceptable behavior and self-control.

A caregiver may also use positive methods of discipline and guidance that encourage self-esteem, self-control, and self-direction, which include at least the following:
- Using praise and encouragement of good behavior instead of focusing only up on unacceptable behavior;
- Reminding a child of behavior expectations daily by using clear, positive statements;
- Redirecting behavior using positive statements; and
- Using brief supervised separation or time out from the group, when appropriate for the child’s age and development, which is limited to no more than one minute per year of the child’s age.

There must be no harsh, cruel, or unusual treatment of any child. The following types of discipline and guidance are prohibited
- Corporal punishment or threats of corporal punishment;
- Punishment associated with food,naps, or toilet training;
- Pinching, shaking, or biting a child;
- Hitting a child with a hand or instrument;
- Putting anything in or on a child’s mouth;
- Humiliating, ridiculing, rejecting, or yelling at a child;
- Subjecting a child to harsh, abusive, or profane language;
- Placing a child in a locked or dark room,bathroom, or closet with the door closed; and
- Requiring a child to remain silent or inactive for inappropriately long periods of time for the child’s age.
Texas Administrative Code, Title 40, Chapters 746 and 747, Subchapters L, Discipline and Guidance

My signature verifies I Have read and received a copy of this discipline and guidance Policy

Signature*
Date*
Date Format: MM slash DD slash YYYY

Check one please*
- Parent
- Employee/caregiver
- Household member of child-care home

Parent

Handbook Agreement

In applying to reserve childcare services for my child(ren), I agree to abide by Tree House Academy policies as set forth in this parent policies agreement.
*
- I acknowledge the receipt of the following policies
- Operating Services & Hours
- Philosophy & Goals
- ADA Statement
- Equal Opportunity Provider
- Curriculum
- Tuition Rates
- Miscellaneous Fees
- Tuition Payments
- General Payment & Tuition Schedule
- Refunds
- Withdrawals
- Holidays
- Ultimate Financial Responsibility
- Admission Procedures & Waiting List
- Safety
- Child Abuse & Neglect
- Childcare Licensing Reports
- Emergency Preparedness
- Arrival & Departure Procedures
- Transportation
- School Age Drop off & Pick up Procedures
- Naptime
- Animals
- Outdoor Play
- Sunscreen
- Water Play & Pool Policies
- Health & Illness Policy
- Medication
- Hearing & Vision Screening
- Nutrition
- Student Meals
- Guidance & Discipline
- Confidentiality Policy
- Class Placement & Promotions
- Clothing & Belongings
- Role of the Parent & Finder’s Fee
- Parent Notifications & Referral Program
- Questions or Complaints
Child(ren)’s Name*

Parent’s Name (please print)*
Date*
Date Format: MM slash DD slash YYYY

Parent’s Signature*
Parent’s Driver’s License Number*

Media

Consent & Release

We would appreciate it if parents completed this consent form in order to allow their children to be photographed or videoed during special events or normal day to day activities organized at Tree House Academy. In order for a child to have their photograph taken or be included in any type of video, they must have a consent form on file at Tree House Academy.

If you do not want to have your child photographed or videoed, please do not hesitate to indicate this in the section below. As well,if you do object, please ensure that your child/children is/are aware of this.

As the parent of a child or children at Tree House Academy, I agree to the following
- I understand that my child(ren) whose name(s) are listed below may be photographed or videoed at Tree House Academy during normal daycare hours,field trips or activities.
- I understand that these photographs and videos may be used in school publications or used on the Tree House Academy website.
- I give permission for my child(ren) to be photographed or videoed and their images recorded to be used on Tree House Academy’s website or publications.
The following are the names of my children attending Tree House Academy (Please print your child’s full name and teacher)*
Media_permission*
- Yes, I confirm that I have read and understood the above,and agree to have my child(ren)’s images used on the Tree House Academy website or publications.
- No, I do not wish to have my child(ren)’s images recorded or used in Tree House Academy’s publications or on the website.
Name (please print)*

Signature*
Date*
Date Format: MM slash DD slash YYYY

Webcasting

Consent & Release

I understand that I have enrolled my child or children at
academy*
located at
Location*

,also referred to herein as the “Day Care”. The Day Care has a program whereby web cam’s are in use and my children are under constant streaming video surveillance that is accessible from the web in accordance with the terms and conditions associated with the Peanut Butter & Jelly, LLC website(also referred to herein as “PB&J”). By my signature below,I hereby consent to the photographing of myself and/or my minor child(ren) and the recording of my voice and or that of my child(ren) named above. I agree that these photographs and/or recordings singularly or in conjunction with other photographs and/or recordings singularly may be used for advertising, publicity, commercial or other business purposes. I further agree that the video footage is the sole property of the above listed facility and may only be used by them. I agree that I have no rights to any of the video footage or photographs for any reason at any time. The video footage will be used for internal training and management within the facility. I understand that the term “photograph” as used herein encompasses both still photographs and motion picture footage.

Since my child/children is/are under the age of 18: I,
parent_name*
,certify that I am the parent/legal guardian of the individual named above, I have read this release and approve of its terms..

Child(ren) Name(s)*
Print Name*

Signature*
Date*
Date Format: MM slash DD slash YYYY

Sunscreen

Application

I,
Sunscreen approve*
- give
- do not give
House Academy permission to apply sunscreen to my child,
Child Name*
, for protection from the sun while he/she participates in outdoor activities with Tree House Academy.

*
- I understand that I am to provide the sunscreen labeled with my child’s name, and only the sunscreen provided by me will be applied to my child.

Parent / Legal Guardian Signature*
Date*
Date Format: MM slash DD slash YYYY

Insect

Repellent Application

I,
insect approval*
- give
- don't give
, give Tree House Academy permission to apply insect repellent to my child,
*
, for protection from the insects while he/she participates in outdoor activities with Tree House Academy

*
- I understand that I am to provide the insect repellent labeled with my child’s name, and only the insect repellent provided by me will be applied to my child.

Parent/Legal Guardian Signature*
Date*
Date Format: MM slash DD slash YYYY

Student

Pick-up Policy

PERSONS AUTHORIZED TO PICK UP CHILDREN:
- Children will not be dismissed to anyone other than the parent/guardian with out prior parent/guardian consent.
- Authorized representatives may pickup with parent /guardian consent must be 18 years of age or older.
- If an authorized representative is picking up the child they must have identification with them as it will be checked against the information provided by the parent /guardian.
- If someone other than those listed as an authorized or emergency pick-up will be picking up your child,written permission must be given.
EMERGENCY INFORMATION:

Tree House Academy keeps emergency information on file for every child. This information lists the current addresses and phone numbers of family members and at least two other authorized persons who may be called in an emergency when the parents/guardian cannot be reached. Persons expressly denied authorization to pick up the child are also listed. It is essential that names and phone numbers be kept up-to-date. Failure to maintain current phone numbersand address can result in loss of child care services.

Parent/Legal Guardian Signature*
Date*
Date Format: MM slash DD slash YYYY

Illness

Policy

Parents are advised to keep their children at home or to seek alternative care arrangements for the following conditions:
- Pain - any complaints of unexplained or undiagnosed pain.
- Runny nose (green mucus indicate infection), watery eyes,coughing,sore throat, or productive cough.
- Difficulty breathing - wheezing or a persistent cough.
- Fever(100 F)
- Sore throat or trouble swallowing
It is required to keep (or take) a child home when the child
- Is suffering from one or more of the above symptoms
- Is not well enough to take part in the regular program of the facility
The child must remain out of the center until they are symptom free without medication for at least 24 hours or accompanied by a doctor’s note authorizing care.

Parent/Legal Guardian Signature*
Date*
Date Format: MM slash DD slash YYYY

Nut Free

Policy

At Tree House Academy we want to insure the health and safety of all our children, families and staff members. Therefore, Tree House Academy is a nut free facility and asks that you not bring any nut products of any kind into the building including Chick-fil-a products as they use peanut oil to fry their food in.

Parent/Legal Guardian Signature*
Date*
Date Format: MM slash DD slash YYYY

Screen

Time Policy

Children over the age of two are limited to two hours per day on “Screen Time” which includes television, tablet, computer and Wii activities. Any child under the age of two years is restricted from any screen time.

Parent/Legal Guardian Signature*
Date*
Date Format: MM slash DD slash YYYY

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Tree House Academy – FERNANDINA BEACH, FL

Admission

Information

Check All That Apply

1.Transportation

2.field trips

3.water activities

4.RECEIPT OF WRITTEN OPERATIONAL POLICIES

5.i understand that the following meals will be served to my child while in care

6.my child NORMALLY in care ON THE FOLLOWING DAYS AND TIMES

AUTHORIZATION FOR EMERGENCY MEDICAL ATTENTION

SCHOOL AGE CHILDREN

CHECK ALL THAT APPLY

IMMUNIZATION RECORD

ADMISSION REQUIREMENT

Discipline &

Guidance Policy

Discipline must be

A caregiver may also use positive methods of discipline and guidance that encourage self-esteem, self-control, and self-direction, which include at least the following:

There must be no harsh, cruel, or unusual treatment of any child. The following types of discipline and guidance are prohibited

My signature verifies I Have read and received a copy of this discipline and guidance Policy

Parent

Handbook Agreement

In applying to reserve childcare services for my child(ren), I agree to abide by Tree House Academy policies as set forth in this parent policies agreement.

Media

Consent & Release

As the parent of a child or children at Tree House Academy, I agree to the following

Webcasting

Consent & Release

Sunscreen

Application

Insect

Repellent Application

Student

Pick-up Policy

PERSONS AUTHORIZED TO PICK UP CHILDREN:

EMERGENCY INFORMATION:

Illness

Policy

Parents are advised to keep their children at home or to seek alternative care arrangements for the following conditions:

It is required to keep (or take) a child home when the child

Nut Free

Policy

Screen

Time Policy

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