Application   

                                                           Children's Montessori School

8736 Baker Avenue

Rancho Cucamonga, CA 91730 (909)982-2146

l/wehereby enroll our child

 

Parent or Guardian Child's Name at Children's Montessori School. My child will attend the Program. My child will attend (full time, part time) agree to pay a weekly tuition ofon the first day of attendance of each week.

Explanation of Contract

I have a copy of the tuition schedule and agree to pay all fees agreed upon in this contract. I understand that all tuition and enrollment fees are non-refundable. I also understand that I will be charged a fee of $10 on top of the tuition agreed too, if payment is late, and is not received on or before the due date agreed too. There will be a $25 return check charge each time a check is returned to this school. A registration fee will be paid at the time of my child's enrollment. If my child is out due to illness, I am still required to pay the fee in full. There will be no credit or refunds for days missed or holidays.

This is required by this contract, that a two-week written notice be submitted to the office prior to termination.

I/We have read and understand the policies and procedures of this contract, and have received a copy of the tuition schedule. I/We also understand that breech of this contract by myself/us in anyway may result in my child's termination from school. My/our signatures below indicate that I/We have read, and agree with, and will abide by the information on this agreement.

             Father or Legal guardian                                                    Date

 

             Mother or Legal Guardian                                                  Date

School Application Form

Date

 

Child's NameNick name

 

              Birthdate                                                         Social Security #

Mother's Name:

 

Social Security #

 

Mother's Occupation: Place of Employment:

 

CDL

Father's Name:

 

Social Security #:

 

Father's Occupation:

 

Place of Employment:

 

CDL

Previous Day Care Experience

Name of Center

 

Dates attended

 

People living in home with child other than parents

 

 

 

 

 

STATE OF CALIFORNIA

HEALTH AND HUMAN SERVICES AGENCY                                                                                                                                                                                                                       COMMUNITY CARE LICENSING DIVISION

IDENTIFICATION AND EMERGENCY INFORMATION

CHILD CARE CENTERS/FAMILY CHILD CARE HOMES

To Be Completed by Parent or Authorized Representative

CHILD'S NAME

LAST

 

MIDDLE

 

FIRST

 

SEX

TELEPHONE

ADDRESS

NUMBER

STREET

 

CITY

 

STATE                    ZIP

BIRTHDATE

FATHER'S NAME

LAST

 

MIDDLE

 

 

FIRST

BUSINESS TELEPHONE

HOME ADDRESS

NUMBER

STREET

 

CITY

 

STATE

HOME TELEPHONE

MOTHER'S NAME

LAST

 

MIDDLE

 

 

FIRST

BUSINESS TELEPHONE

HOME ADDRESS                  NUMBER

STREET

 

CITY

 

STATE

HOME TELEPHONE

PERSON RESPONSIBLE FOR CHILD

LAST NAME

MIDDLE

FIRST

 

HOME TELEPHONE

BUSINESS TELEPHONE

ADDITIONAL PERSONS WHO MAY BE CALLED IN AN EMERGENCY

NAME

ADDRESS

TELEPHONE

RELATIONSHIP

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PHYSICIAN OR DENTIST TO BE CALLED IN AN EMERGENCY

PHYSICIAN

ADDRESS

MEDICAL PLAN AND NUMBER

TELEPHONE

DENTIST

ADDRESS

MEDICAL PLAN AND NUMBER

TELEPHONE

IF PHYSICIAN CANNOT BE REACHED, WHAT ACTION SHOULD BE TAKEN?

 

NAMES OF PERSONS AUTHORIZED TO TAKE CHILD FROM THE FACILITY

(CHILD WILL NOT BE ALLOWED TO LEAVE WITH ANY OTHER PERSON WITHOUT WRITTEN AUTHORIZATION FROM PARENT OR AUTHORIZED REPRESENTATIVE)

NAME

RELATIONSHIP

 

 

 

 

 

 

 

 

 

 

TIME CHILD WILL BE CALLED FOR

SIGNATURE OF PARENT OR AUTHORIZED REPRESENTATIVE

DATE

TO BE COMPLETED BY FACILITY DIRECTORIADMINISTRATOR/FAMILY CHILD CARE HOMES LICENSEE

DATE OF ADMISSION

DATE LEFT

LIC

 

STATE OF CALIFORNIA

HEALTH AND HUMAN SERVICES AGENCY    COMMUNITY CARE LICENSING PHYSICIAN'S REPORT—CHILD CARE CENTERS

(CHILD'S PRE-ADMISSION HEALTH EVALUATION)

 

PART A - PARENT'S CONSENT (TO BE COMPLETED BY PARENT)

, bornis being studied for readiness to enter

                                                              (NAME OF CHILD)                                                                                                  (BIRTH DATE)

. This Child Care Center/School provides a program which extends from

(NAME OF CHILD CARE CENTER/SCHOOL)

           a.m./p.m. to                        a.m./p.m. ,days a week.

 

 

 

(SIGNATURE OF PARENT, GUARDIAN, OR CHILD'S AUTHORIZED REPRESENTATIVE)

(TODAY'S DATE)

 

 

PART B -PHYSICIAN'S REPORT (TO BE COMPLETED BY PHYSICIAN)

 

 

 

 

 

ro emso w

you s ou

e aware:

 

 

 

eanng:

 

 

 

erges:me Icine:

 

ISIon:

 

 

 

nsect stings:

 

eve opmental:

 

 

 

 

nguage peec

 

 

asthma:

 

 

 

 

 

other:

 

ther ncu e e avora concerns :

 

 

 

 

 

omment XP anations:

 

 

 

 

 

                 

Please provide a report on above-named child using the form below. I hereby authorize release of medical information contained in this report to the above-named Child Care Center.

 

IMMUNIZATION HISTORY: (Fill out or enclose California Immunization Record, PM-298.)

VACCINE

DATE EACH DOSE WAS GIVEN

 

1st

2nd

3rd

4th

5th

POLIO (OPV OR IPV)

 

 

 

 

 

(DIPHTHERIA, TETANUS AND

DTP/DTaP/                          PERTUSSIS OR TETANUS

[ACELLULARI

DTITd                  AND DIPHTHERIA ONLY)

 

 

 

 

 

(MEASLES, MUMPS, AND RUBELLA)

MMR

 

 

 

 

(REQUIRED FOR CHILD CARE ONLY)

HIB MENINGITIS   (HAEMOPHILUS B)

 

 

 

 

HEPATITIS B

 

 

 

 

VARICELLA                    (CHICKENPOX)

 

 

 

 

SCREENING OF TB RISK FACTORS (listing on reverse side)

Risk factors not present; TB skin test not required.

Risk factors present; Mantoux TB skin test performed (unless previous positive skin test documented).

Communicable TB disease not present.

 

 

             

            I have                   have not                           reviewed the above information with the parent/guardian.

            Physician:    Date of Physical Exam:

            Address:    Date This Form Completed:

            Telephone:   Signature

C) Physician

                   LIC        (8/01) (Confidential)

STATE OF CALIFORNIA-HEALTH AND HUMAN SERVICES AGENCY

COMMUNfTY CARE UCENSiNG

CHILD'S PREADMISSION HEALTH HISTORY—PARENT'S REPORT

               CHILD'S NAME                                                                                                                                                                                              SEX BIRTH DATE

               FATHERS/FATHERS DOMESTIC PARTNER'S NAME                                                                                                                                          •DOES FATHER/FATHERS DOMESTIC PARTNER LIVE IN HOME WITH CHILD?

              MOTHER'S/MOTHER'S DOMESTIC PARTNER'S NAME                                                                                                                                    DOES MOTHENMOTHER'S DOMESTIC PARTNER LIVE IN HOME WITH CHILD?

                IS [HAS CHILD BEEN UNDER REGULAR SUPERVISION OF PHYSIC\AN?                                                                                                                DATE OF LAST PHYSICALNEDICAL EXAMINATION

DEVELOPMENTAL HISTORY (*For infants and preschool-age children only)

              WALKED                                                                                                      BEGÄÉ< tALKiNG                                                                                          toiLET TRANiNG STÅRTEÖ At'

                                                                                              MONTHS                                                                                                     MONTHS                                                                                                     MONTHS

PAST ILLNESSES— Check illnesses that child has had and specify approximate dates of illnesses:

                                                                  DATES                                                                   DATES                                                                   DATES

                 Chicken Pox                                                            Diabetes                                                              Poliomyelitis

                 Asthma                                                                    Epilepsy                                                               Ten-Day Measles

(Rubeola)

                 Rheumatic Fever                                                    Whooping cough

Three-Day Measles

                Hay Fever                                                              Mumps                                                               (Rubella)

SPECIFY ANY OTHER SERIOUS OR SEVERE ILLNESSES OR ACCIDENTS

HOW MANY IN LAST YEAR?                 LIST ANY ALLERGIES STAFF SHOULD BE AWARE OF DOES CHILD HAVE FREQUENT COLDS?      YES                  NO

DAILY ROUTINES (*For infants and preschool-age children only)

               WHAT TIME DOES CHO GET                                                                       WHAT TiME DOES CHILD GO TO                                                                         DOES CH\LD SLEEP

                DOES CHILD SLEEP DURING THE                                                                                                                                                                                           HOW

DIET PATTERN: BREAKFAST        WHAT ARE USUAL EATING HOURS? (What does child usually      BREAKFAST eat for these meals?) LUNCH                   LUNCH

DINNER

DINNER

               ANY FOOD DISLIKES?                                                                                                                                                                ANY EATING PROBLEMS?

                   CHILD TOLET                                                             IF YES. AT WHAT                                                            ARE BOWEL MOVEMENTS                                            WHAT IS USUAL TIME?

Cl YES

              WORD USED FOR "BOWEL                                                                                                                                     WORD USED FOR

PARENT'S EVALUATION OF CHILDS HEALTH

         es CHiLD PRESENTLY UNDER A DOCTORS CARE?  YES,NAME OF DOCTOR:                                        DOES CHILD TAKE PRESCRIBED                            IF YES, WHAT KIND AND ANY SIDE EFFECTS:

                 YES               NO                                                                                           YES         El NO

                DOES CHILD USE ANY SPECIAL DEVICE(S):                  IF YES, WHAT KIND:                                                         DOES CH\LD USE ANY SPECIAL DEViCE(S) AT HOME? ; IF YES, WHAT KIND:

                 YES                                                                                                               YES

PARENT'S EVALUATION OF CHILD'S PERSONALITY

HOW DOES CHILD GET ALONG WITH PARENTS, BROTHERS, SISTERS AND OTHER CHILDREN?

HAS THE CHILD HAD GROUP PLAY EXPERIENCES?

DOES THE CHILD HAVE ANY SPECIAL PROBLEMSiFEARS/NEEDS? (EXPLAIN.)

WHAT ts THE PLAN FOR CARE WHEN THE CHILD ILL?

REASON FOR REQUESTING DAY CARE PLACEMENT

               PARENTS SIGNATURE                                                                                                                                                                                                                                                              DATE

(8'08) (CONFIDENTIAL)

AUTHORIZATION TO CONSENT TO •TREATMENT OF MINOR

 I (We) the undersigned parent(s) or legal guårdian of (child's name) a minor, do•hereby authorii& and consent to any x-iay examination, anesthetic,.medical •or surgical diagnosis or freaånent and hospital' care which is deemed advisable by and rendered:under the general or special supervision ofany merilber ofthe medical staffand emergency room• staffliéensed under the proVisions of the Medical Practice Act or a dentist licensed under the Dental Practice Act and . on the staff of any acute general hospital hölding a current license to operate a hospital from the State Department-ofPublic Health. It is understood that this authorization is. given. in advance of any specific diagnosis, or .hospital care being required but is given to provide authority and power to render care vvhich the aforementioned physician.frl the exercise of his best judgrnent may deem advisable. It is understood that effort shall be made- to contact fhe undersigned prior to rendering treatment to the patient, but Hiat any •of the above treatrnent will not be. with held if the undersigned can not be reached. Any cost not covered by insurance Fill be paid. for by the undersigned.

This aüthörizatiQp is given •purs.uant to theprovisions of Sectiorr 25.8 of the. Civil Code of California.

Last' Tetanus

Toxoid Booster.

 

Allergies to      

Drugs or Food.

 

 

ignature ofP.arent(s) or Legal Guardian.                                      Date