PC Tots Early Learning Center Child Admission Agreement
NameofChild
Nickname
Date_________
BirthDate
Sex
EnrollmentDate
month/day/year
(checkone)
(checktheboxifnolongerenrolled)
___/____/_____
F____M____
___/____/_____☐
___/____/_____
F____M____
___/____/_____☐
___/____/_____
F____M____
___/____/_____☐
HomeStreetAddress____________________________________________Phone#_____________________
City_______________________________________________________State______Zip_________________________
Mother’s/Guardian’sName_____________________________________Phone#_______________________
Employer___________________________________________________WorkPhone#______________________
Father’s/Guardian’sName_______________________________________Phone#______________________
Employer____________________________________________________WorkPhone#______________________
Primaryemail_______________________________________________________________________________________
AverageHouseholdGrossIncome________________________________________________________________
Myrequestedstartdateis____________________________________________________________________________________
EmergencyContacts(OtherthanParents)andPersonsAuthorizedtoPick-UptheChild(Unless
thereisacourtorderprohibitingit,parentswhosenamesarenotlistedcanpickuptheirchildren.)
Name
RelationshiptoChild
Address
Phone#
☐Checkiftherearenoemergencycontactsavailable,otherthanparents.
☐Checkiftherearenopersonsauthorizedtopickupthechild,otherthanparents.
OutofArea/StateContactName(Ifavailable) RelationshiptoChild
Address
Phone#
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IherebygrantexclusivepermissionforPCTotsanditsagentstousemychild’snameandphotograph
forthepurposeofpublicity,publicrelations,editorialorotheradvertisingpurposewithout
restrictionastofrequencyorduration.IalsoagreethatneithermyminorchildnorIwillbeentitled
toanycompensationinexchangeformygrantingthisexclusivepermissiontoPCTotsanditsagents.
☐YES☐NO ___________________________________________________________________________/______/___________
IherebygivePCTotspermissiontotakemychildonfieldtripsoutsidethePCTotsCenterusing
publictransportation(parentswillbenotifiedofthetypeandlocationoffieldtripsbeforedeparture).
☐YES☐NO_____________________________________________________________/______/___________
Iunderstandthat:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
Incaseofemergencyorseriousillness,whenparentscannotbereachedimmediately,I
herebyauthorizethePCTotstoobtainemergencymedicalcareand/orprovideemergency
medicaltransportationformychild.
PCTotspoliciesregardingtuitiondeposits,refundpolicies,latefeecharges,andlatepickup
charges.
My child’s immunizations are CURRENT and will be kept UP TO DATE__________(Initial)
IwillkeepthePCTotsinformedofanynewimmunizationsmychildhasreceived.
IwillimmediatelynotifytheCenterifmychildcontractsaninfectionsdisease.
TheCenter’slicensingagencyshallhavetheauthoritytointerview,inspect,andauditclients,
childrenandstaff.Licensingagencyalsohastheauthoritytoexamineallrecordsrelatedto
theoperationofthePCTotsCenter.
Iexpecttobetreatedwithrespectbyallstaff,andIwilltreatallPCTotsstaffwithrespect.
IwillkeeptheCenterinformedofanychangedinmyfamilystatus,suchasnewphone
number,addressorcircumstancesthatmightaffectmychild’sbehavior.
Iwillcompleteallformsasrequiredforenrollment.
Iunderstandmychild’sDOBmaybeverifiedwithotherlicensedagencies.
Iunderstandthatmychildwillnotbesubjecttocorporalpunishmentorunusual
punishment,inflictionofpain,humiliation,intimidation,ridicule,coercion,mentalabuseor
otheractionsofpunitivenature,includingbutnotlimitedto,interferencewiththedaily
livingfunction,suchaseating,sleepingandortoileting.
IunderstandthatIhavetherighttoinspectand/ordropinthecenteratanytimeorhave
accesstomychildatanytime.
IunderstandthatifPCTotswillcontactmeifmychildcriesuncontrollablyfor30minutesor
showssignsofillness,thechildmustbepickedupfromthecenter.
___________________________________________________________________________/______/___________
SignatureofParentorGuardianDate
ForOfficeuseonly
☐ImmunizationRecords
☐HealthAssessment
☐EmergencyCard
☐ParentHandbook
☐UTStateChildcareGuide
☐GettingtoKnowYourChild
☐MedicationAdministrationForm
☐FamilyOrientationDate_________
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PCTotsChildHealthAssessment
PleaseWriteClearly.Theremustbeaseparatehealthassessmentformforeach
sibling.
NameofChild_________________________________________BirthDate______/______/___________
CheckAllThatApply:
Doesyourchildhaveanyknownallergiesorsensitivitiesto:NoYesIfyes,please
list:
Medications Yes☐No____________________________________________________________________
Foods
Yes☐ No☐_________________________________________________________________ Othe___________________________________________________________________________________________
IllnessesorMedicalConditions:
Doesyourchildhaveanyofthefollowing:No/Yes
AsthmaYes☐No☐
VisualImpairmentYes☐No☐
DiabetesYes☐No☐
DevelopmentalDelaysYes☐No☐
SeizuresYes☐No☐
HeartProblemsYes☐No☐
HearingImpairmentYes☐No☐ PhysicalImpairmentYes☐No☐
BehavioralorEmotionalProblemsYes☐No☐
Other__________________________________________________________________________________________
Listanyregularmedicationsyourchildtakes:
_________________________________________________________________________________________________
NameofChild’sMedicalProvider:
_________________________________________________________________________________________________
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Listanyadditionalhealthinformationorspecialinstructionsyoufeelweneedtobe
awareof:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Reviewedand/orupdate:______/______/______Parent/Guardian
Signature_________________________________
Reviewedand/orupdate:______/______/______Parent/Guardian
Signature_________________________________
Reviewedand/orupdate:______/______/______Parent/Guardian
Signature_________________________________
_____________________________________________________________________/______/______
Parent/GuardianSignatureDate
Thisformmustbecompletedforeachindividualchildenrolled,andmustbe
reviewedannuallybytheparent/guardian,andanychangesnoted.
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GettingToKnowYourChildAssessmentForm
NameofChild_________________________________________________________________________________
NameofParents/Guardians_________________________________________________________________
1.Health
Doesyourchildhaveanyallergies
Yes☐
No☐
Ifso,whatallergiesdoesyourchildhave? Howshouldwerespondifyourchildhas
anallergicreaction?
Doesyourchildhaveanexistingillness?
Yes☐
No☐
Yes☐
No☐
Hasyourchildhadapreviousserious
illnessorinjury,orhospitalization
duringthepast12months?
Isyourchildtakinganymedication?
Ifso,howisthemedication
administered,andwillitneedtobe
administeredwhilehe/sheisincare?
Isthemedicationprescribedfor
continuoususe?
Arethereanysideaffectsweshouldbe
alertedto?
2.Toileting
Doesyourchildneed
Yes☐
assistancewithtoileting?
Howcanwebesthelp?
Whatareyourideasabout toilettraining?
Howcanwebesthelp?
Yes☐
No☐
Yes☐
No☐
Yes☐
No☐
No☐
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3.Behavior
Howdoesyourchildcommunicate
his/herneeds?
Arethereanyspecialwordsthatyour childusesthatmightnotbereadily
recognized?
Howdoyoutellyourchildtostopa
behaviorthatyoudon’tapproveofor
thatmightbedangerous?
Whenyourchildgetsupset,what
helpshim/hercalmdown?
Whatisagoodwaytodistractyour
childwhenhe/sheishavingatemper
tantrum?
Arethereanyparticularroutinesthat areparticularlyhelpfulatnaptime?
Whatpositionismostcomfortablefor yourchildwhenhe/sheisnapping?
Doesyourchildhaveanyunique
fears?
4.Eating
Doesyourchilduseutensils,eat
withfingers,feedself?
Yes☐
No☐
Yes☐
No☐
Doesyourchildchokeeasilywhile
eating?
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5.Activities
Whatactivitiesdoyouliketo
dowithyourchild?
Whatactivitiesdoesyour
childliketodowhenplaying
withotherchildren?
Whatdoesyourchildliketo
dowhenheisplayingalone?
6.Infants
Howdoesyourchildfall Yes No asleep(i.e.Rocking,
hushing,)?
Whatpositiondoes
yourinfantpreferwhen
drinkingabottle?
Isyourinfanteating
Yes No solids?
Whatgrossmotor
milestonehasyour
childreached(i.e.
tummytime,crawling,
cruising,walking)?
Ifyouareplanningtocontinuetobreast
feedwhileyourchildisinthecareofPC
Tots,weencourageyoutonurseatour
center.Wewillprovideaprivatearea
youcancomfortablynurseyourbaby.
Pleaseletusknowwhattimesyouplan
onnursingyourbabyatthecenter.
AdditionalComments
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Parent/GuardianSignature________________________________________Date___________________
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