Smart-Start Quality Child Care Enrollement 2023

Enrolled Child's First and Last Name

Enrolled Child's Date of Birth:

Preferred Nickname (Opt.)

Enrolled Sibling's First and Last Name:

Enrolled Sibling's Date of Birth:

Preferred Nickname (Opt.)

Address(es) of Enrolled Child(ren):

Address

Address Line 2

City

State

Zip

Parent/Guardian #1:

Name

Relationship to Child

Phone

Job Title/Company Name

Work Phone

E-Mail Address

(Skip if same as enrolled child's address)

Address

City

State

Zip

Parent/Guardian #2

Name

Relationship to Child

Phone

Job Title/Company Name

Work Phone

E-Mail Address

(Skip if same as enrolled child's address)

Address

City

State

Zip

If neither parent can be contacted, who should we contact in case of emergency?

Name

Relationship to Child

Phone

Additional contacts to be added to child's emergency/pick-up list: Please include full names and contact numbers:

Medical Permissions:

I hereby give permission to SSQCC personnel to obtain medical or surgical care from a health care facility, physicians, or dentists for my child, should the need arise. It is understood that a conscientious effort will be made to locate me before action is taken. If this is not possible, treatment as deemed necessary by the physicians/dentists may be taken. I further consent to transportation of the above-named child to the nearest or most appropriate medical facility. I understand that I am financially responsible to providers of service for charges not covered by insurance payments.

Parent/Guardian Initials:_____

My Insurance provider is:

Numbers/information pertaining to coverage:

Child's Known Allergies/Intolerance:

Legal Restrictions Regarding Child(ren)

Please breifly describe restrictions:

Upload any legal documents pertaining to restrictions:

Upload

or Drag and Drop a File

Authorization for Sunscreen, Ointments, and Insect Repellent
I give my permission for SSQCC staff to apply sunscreen or other topical medications which include spray, lotions, and ointments (including diaper rash ointment provided by the parent) as needed and insect repellent containing deet when insects are present. I will provide specific instructions or exceptions for use if there is a medical reason requiring application to be different than the instructions on the bottle. This agreement also covers aroma-therapy essential oils to be allowed as diffused vapor in the classrooms.

Exceptions to topical product use:

Parent/Guardian Initials:_____

Use of Wading or Swimming Pools (12 months & older)

I hereby give permission for my child to participate in any swimming or water activities (including wading pools and slides) at the SSQCC. Children will be instructed on the safe use of swimming pools and the slide. An adult will be on duty at all times when the pools are available and extra safety precautions will be taken.

Parent/Guardian Initials:_____

Rock-Wall Permission (3+)

Smart-Start has recently finished installing our traverse climbing wall to host these exciting activities. Participants climb horizontally (traverse) across the wall and their feet should never be higher than 36”/42” from the safety mats. Your child will be taught safety rules and will climb under the careful supervision of an adult instructor at all times

Parent/Guardian Initials:_____

Indemnity Clause
The undersigned below acknowledges and agrees that in the normal day-to-day operations of dealing with children, there are normal and ordinary accidents and injuries, including SIDS, which occur in the usual and customary course of business. By signing below, the party acknowledges and agrees that they will hold Dee Harrison, Donna Harrison, Smart-Start Academy LLC and smart-Start Quality Childcare Center and its employees harmless against any and all claims, actions, demands, losses or liabilities arising to persons or property as a result of the daily operations of Smart-Start Academy, LLC.

Parent/Guardian Initials:_____

DFS licensing rules require Smart-Start to keep up-to-date immunization records on file for every enrolled child above the age of 12 months.You will be notified if your child's immunization records are not in their file.

If available digitally, please upload child's immunization records here, or provide physical copy to child care:

Upload

or Drag and Drop a File

Parent/Guardian Signature: ______________________________________ Date:_____________________________

By clicking the above button, I consent to be contacted by Smart-Start Quality Child Care, Inc. and Webit, Inc. at any email address or telephone number I provide, including, without limitation, communications sent via text message to my cell phone or communications sent using an autodialer or prerecorded message. This acknowledgement constitutes my written consent to receive such communications. I agree and consent to any applicable Terms and Conditions of Use or Privacy Policy available on this website.

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After submission, your printed form will be provided in a classroom for a parent/guardian to sign.