Application | FootprintstoScholars

FOOTPRINTS TO SCHOLARS LEARNING CENTER, LLC

3754 Pleasantdale, Road

Doraville 30340

(470) 395-5145(office)

footprintstoscholars@gmail.com

ENROLLMENT FORM

Date of Enrollment

Withdrawal Date

Child's Name

Sex

Age

Date of Birth

Address

City

State

Zip Code

Mother's Name

Mother's Place of Employment

Employment Address

Phone Number

Mother's Address (If different than child)

Work Phone

City

State

Zip Code

Father's Name

Phone Number

Father's Address (If different than child)

Father's Place of Employment

Work Phone

Employment Address

City

State

Zip Code

Child's Living Agreements:

Check one:

Both Parents

Mother

Father

Other

Child's Legal Guardian(s):

Check one:

Both Parents

Mother

Father

Other

RELEASE AGREEMENT

The child may be released to the person(s) signing this agreement or to the following: MUST SHOW ID

1. Name

Address

Phone Number

City

State

Zip Code

2. Name

Address

Phone Number

City

State

Zip Code

Emergency Contacts:

Persons to contact in the case of emergency when a parent or guardian cannot be reached:

Name

Phone Number

Name of Public or Private School child attends, if any:

Child's Doctor or Clinic Name

Doctor/Clinic Phone

My child has the following special needs:

The following special accommodation(s) may be required to most effectively meet my child’s needs while at the center.

My child is currently on medication(s) prescribed for long-term continuous use and/or has the following pre-existing illness, allergies, or health concern:

Emergency MEDICAL AUTHORIZATION:

Should

Child's Name

Date of Birth

Suffer an injury or illness while in the care of FOOTPRINTS TO SCHOLARS CHILDCARE, LLC and the facility is unable to contact me (us) immediately, it shall be authorized to secure such medical attention and care for the child as may be necessary. I (we) shall assume responsibility for payment for services.

Parent/Guardian (PRINT)

Date:

Your Signature

(OFFICE USE) Facility Administrator/Person-Charge-Charge (PRINT)

Signature

Date:

Footprints To Scholars Learning Center agrees to provide child care for:

Child's Name

Days of the Week

from

Start Time

End Time

Start Month

End Month

Full time hours are defined as any 10 hour period during hours of operation

My child will participate in the following meal plan (Please check):

Photography/Video Release

Parent/Guardian (PRINT)

I ___________________________ give permission to Footprints to Scholars to photograph and video in the center before and during functions that takes place while my child is in attendance. I understand photograph and video may be taken by center staff or by other parents or guardian.

Parent/Guardian Signature

Date:

HOLIDAYS

New Year’s Day, DR. Martin Luther King Day, Memorial Day, Independence Day, Labor Day, Thanksgiving Day and the after thanksgiving, Christmas Eve and Christmas Day and otherwise specified in advanced by Footprints to Scholars.

FOOTPRINTS TO SCHOLARS LEARNING CENTER CONFIDENTIAL AGREEMENT, all information pertaining to the child pertaining to the child record will remain confidential and may not be released by the center staff without written permission signed by the parents/guardian except for the following situation: behavior characteristics on the children enrolled, medical status or in the vent of a medical emergency

Our Emergency Plan is located in the front lobby on the information board readily available and visible for all parents to review.

Parent/Guardian Signature

Date:

MEDICATION AUTHORIZATION

Before any medication is dispensed to my child, I will provide a written authorization, which includes: date; name of child; name of medication; prescription number; if any; dosages; date and time of day medication is to be given. Medicine will be in the original container with my child’s name marked on it.

Footprints to Scholars will only emergency medications such as epipens and asthma meds. ALL Mediations must be checked in at the front desk with a Director.

My child will not be allowed to enter or leave the facility without being escorted by the parent(s), person authorized by parent(s), or facility personnel.

I acknowledge it is my responsible to keep my child’s records current to reflect any significant changes as the occur, e.g., telephone numbers, work location, emergency contacts, child’s physician, child’s health status, infant feeding plans, and immunization records, etc.

The facility agrees to keep me informed of any incident, including illnesses, injuries, adverse reactions to medications, etc., which include my child.

Footprints to Scholars Learning Center agrees to obtain written authorization from me before my child’s participates in routine transportation, field trips, special activities away from the facility, and water-related activities occurring in water that is more than two (2) feet deep.

I authorize Footprints to Scholars Learning Center to obtain emergency medical care for my child

_____________________________________ when I am not available.

Child's Name

I have received a copy and agree to abide by the policies and procedures for Footprints to Scholars Learning Center.

I understand Footprints to Scholars Learning Center will advise me of my child’s progress and issues relating to my child’s care as well as any individual practices concerning my child’s special needs. I also understand that my participation is encouraged in facility activities.

Parent/Guardian Signature

Date:

Facility Administrator Signature

Date:

FOOTPRINTS TO SCHOLARS CHILDCARE LLC POLICIES

Hours of operation 6:30 a.m. to 6:30 p.m. Monday thru Friday (COVID 7am-5pm)

Full Time hours are considered any 10 hours during normal hours of operation

A two weeks written notice must be given before disenrolling your child or your account will be charged for two weeks full tuition
Any attendance of one to five days; tuition must be paid for a full week
Zero days, tuition must be paid for half a week to reserve your child’s space
Tuition fees are due on Friday for the upcoming week in advance
If not paid by Friday, a $25.00 late fee will be added
If your check returns for any reason, a $35.00 fee will be charged
After 6:30 p.m. there will be a late pick up fee of $1.00 per minute, per child
Current immunization record form 3231 with enrollment (Must be kept current).
All children must have a change of clothing at the center
Please do not bring candy, gum, toys, money, food or jewelry to school
State law, children with 100 degree or higher temperatures cannot remain at the center. Must be fever free for 24 hours
Children with communicable (contagious) diseases will not be allowed in the center
If your child does not adjust to our program, we reserve the right to disenroll him/her from our program
Parents are permitted access to all parts of the center at any time their child is present
We are not responsible for lost, damage, stolen, clothing or other items worn or brought to the center

Please label all clothing, cups, and bottles with your child’s name and date

If Dekalb County Schools are closed due to inclement weather.
All medications must be left at the front desk with a signed medication authorization
WE WILL ONLY ADMINISTER EMERGENCY MEDS (such as asthma pumps and epipens)
Your child must be at the center before 10AM unless otherwise specified in agreement

Please be courteous and pick up on time.

HOLIDAYS

New Year’s Day, Dr. Martin Luther King Day, Memorial Day, Independence Day, Labor Day, Thanksgiving Day and the after thanksgiving, Christmas Eve, Christmas Day and otherwise specified in advanced.

I, ______________________________________ agree to abide by all policies and procedures.

Child's Name

Signature

Date:

Thank you for submiting your online enrollment form at Footprints to Scholars!

Relationship to Child

Relationship to Parent or Guardian