ADMISSION AGREEMENT: 2015- 2016

My child _____________________________________ will be enrolled in the ELBA. My childs start date will be ________________, and
he/she will be attending on the following schedule. Monday-Friday am / pm.
FEES
I agree to pay the annual registration of $50.
I agree to pay a weekly fee of $_________for each week my child is enrolled at the OGSD Child Care Center.
There are no credits or refunds for absences or holidays.
PAYMENT
The weekly fee must be paid in advance each Monday by 6 p.m. for the current week of attendance.
All fees must be paid by check or money order payable to OGSD and received in the tuition box located in the parent area at the center
before 6 p.m. on Monday of each week, or the first Monday of the month.
After the above specified Monday, at 6 p.m. a late payment fee of $25.00 will be charged. The full amount of the weekly fee and the
late fee must be paid no later than the following Thursday at 6 p.m., or services for your child will be suspended. To resume services,
we will expect full payment of the outstanding balance and full payment for the next week.
A late pickup fee of $1 per minute per child is charged after the scheduled pick-up time, payable the following Monday.
If two checks are returned by the bank for insufficient funds, the OGSD Child Care Center will accept payment only by money order.
A $20.00 bank charge will be assessed on all returned checks.
The center may increase or add program fees only with a written notice to all families 30 calendar days in advance of the change.
BASIC SERVICES
Days and hours of service are from 7:30 am to 6:00 pm
Ages served are three years to five years.
The schedule of holidays/vacation days when the center is closed is attached.
ELBA will provide nutritious daily breakfast and snacks. If my child requires a special diet, I will provide meals and snacks from
home.
ELBA holds an open door visiting policy.
The names and qualifications of all staff currently employed at the center are posted in the Parents Area.
OPTIONAL SERVICES
The days and times of a childs enrollment may be changed, on a space available basis in consultation with the director, and at least one week
in advance.
COURT ORDERS
If there are court orders regarding your child, for example: Family Court, Juvenile Court or Probate Court orders, the ELBA REQUIRES that
you notify and inform the Academy of any pertinent court orders that apply to your child. All court orders will be followed to the letter. If
the court order has been modified or changed, it must be in writing from the court.
PARENTS RESPONSIBILITIES
Parents are required to sign children in and out of the center each day.
Parents are required to notify the center of the following:
o Prescription medication the child needs to take while at the center.
o Infectious or communicable diseases, including head lice, in the family.
o Childs absence from the center on a scheduled day.
o Any changes in the childs enrollment status or of information contained in the childs file.
o Childs departure from the program (two weeks notice).
ELBA is not liable for personal items that are lost, broken or stolen.
For complete information on ELBA policies and procedures, please refer to the Program Handbook.
CONDITIONS FOR PARTICIPATION AND TERMINATION
The ELBA admits children regardless of race, religion, sex, or national origin.
I understand that the department responsible for the licensing of the ELBA has the right and authority to inspect the center, to
interview children, and to inspect and audit childrens records without prior consent.
The licensing agency shall have the authority to observe the physical condition of the child(ren), including conditions which could
indicate abuse, neglect, or inappropriate placement, and to have a licensed medical professional physically examine the child(ren).
We reserve the right to exclude a child from attendance at ELBA at the discretion of the Program Director. Grounds for exclusion
include the following: health, disruptive behavior, failure to follow center/ELBA policies, delinquent payment of fees, excessive late
pickup, physical and/or verbally abusive behavior by children or parents to children, parents or staff.
______________________________________________
Parents Signature

____________________________
Date

______________________________________________
Directors Signature

____________________________
Date

IDENTIFICATION AND EMERGENCY INFORMATION

Childs Name: _____________________________ Sex: ______ Birth date: ____________ Home Phone: _____________
Address: __________________________ City: _____________ Zip: __________ email ___________________________
Fathers Name: ______________________ Fathers employer: __________________________Wk #:________________
Fathers address if different from childs __________________________________________________________________
Mothers Name: _____________________ Mothers employer: __________________________Wk #:________________
Mothers address if different from childs _________________________________________________________________
Persons responsible for child: ____________________________

Cell # __________________________

Persons responsible for picking up child from the center. (Child will not be allowed to leave with any other person without authorization from
parent.)
Father: Yes____ No ____
Name

Mother: Yes____ No _____

ADDRESS

Physician or dentist to be called in an emergency:

PHYSICIAN/DENTIST
ADDRESS

PHONE

RELATIONSHIP

MEDICAL PLAN & NO.

PHONE

ALLERGIES: Medication________________________________ Special problems: Cardiac ______________________

Bee stings _________ Convulsions ___________ Diabetic __________ Foods___________________
Other (please explain) __________________________________________________________________
Date of:

Last Tetanus____________________

Last Physical _______________________

If physician cannot be reached, what action should be taken?

Call emergency hospital_______________________________________________________.
Consent for Medical Treatment:
As the parent/guardian, I hereby give consent to the OGSD to provide all emergency dental or medical care prescribed by a duly licensed
physician or dentist for (child) ________________________. This care may be given under whatever conditions are necessary to preserve the
life, limb or well-being of my dependent. I will accept the expense of this service.
Parent/Guardian Signature: ________________________________________________ Date: ___________________
Date Enrolled ____________
04-1681 S (ESD 05/13)

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

CONSENT FOR EMERGENCY MEDICAL TREATMENTChild Care Centers Or Family Child Care Homes

AS THE PARENT OR AUTHORIZED REPRESENTATIVE, I HEREBY GIVE CONSENT TO

TO OBTAIN ALL EMERGENCY MEDICAL OR DENTAL CARE
FACILITY NAME

PRESCRIBED BY A DULY LICENSED PHYSICIAN (M.D.) OSTEOPATH (D.O.) OR DENTIST (D.D.S.) FOR
. THIS CARE MAY BE GIVEN UNDER
NAME

WHATEVER CONDITIONS ARE NECESSARY TO PRESERVE THE LIFE, LIMB OR WELL BEING OF THE CHILD
NAMED ABOVE.

CHILD HAS THE FOLLOWING MEDICATION ALLERGIES:

DATE

PARENT OR AUTHORIZED REPRESENTATIVE SIGNATURE

HOME ADDRESS

HOME PHONE

WORK PHONE

04-1674 ESD

)
LIC 627 (9/08) (CONFIDENTIAL)

This form is optional. Please fill out

any information you think will help us
understand and provide better services
for your child.
FAMILY AND SOCIAL HISTORY
Childs Name: _____________________________ Nickname: ________________Birth date: ________________
Mothers Name: ___________________________ Age: _______ Occupation: ____________________________
Fathers Name: ___________________________ Age: ________Occupation: ____________________________
Would the parent be willing to visit the center and share their occupation with the children? __________
Other members of the household:
Name

Relationship

Age

What is the status of the childs parents? Married

Grade

Separated Divorced Widowed

Has the parent remarried? Yes No

Does the child see the other parent? Yes No

Are there any problems? Yes

If so, what? _____________________________________________.

No

How often does the child visit? __________________________________________________________________.

Is the child adopted?

Yes

No

Family hobbies and interests: __________________________________________________________________

Family pets: Names and kinds: _________________________________________________________________
Does the child have a room alone? Yes

No If not, whom do they share with? _______________________

Has child been cared for by anyone other than the parents? Yes No
If so, by whom and where? ___________________________________________________________________
Other school experience? Yes No Where? ________________________________________________
Does the child prefer to play alone? Yes No

With others? Yes

No

Favorite toys: ______________________________________________________________________________

Does the child enjoy being read to? Yes No Does he/she read? Yes No
Favorite stores: ____________________________________________________________________________

School

FAMILY AND SOCIAL HISTORY (continued)

Childs Name: _________________________________ Date: __________________
Has the child had any experience in any of these areas?
Trikes
Clay
Waterplay

Swings
Scissors
Music

Slides
Painting
Paste

Climbing
Puzzles
Animal Care

Sand
Blocks
Math

Jumping
Books
Language

How does the child get along with family and others? _______________________________________.
Is the child right or left handed? __________________
What are the childs talents or special interests that we could help develop?
__________________________________________________________________________________
In what areas does the child need help? __________________________________________________
Language development:

Average

Slow

Advanced

Emotional development:

Independent

Dependent on parent If so, how much? ____________

Any problems? ______________________________________________________________________

Temper outlets:

Thumb-sucking Nail-biting

Stuttering

Other: _________________

Explain napping habits if any: _________________________________________________________

Parents reason for enrolling child: ______________________________________________________
Behavior methods used at home: _______________________________________________________
Best Response: _____________________________________________________________________
Parents evaluation of childs emotional maturity: ___________________________________________
Previous child care center attended if any: ________________________________________________
________________________________________
Parent/Guardians Signature

_________________________
Date