Enrollment Form

Dear Academy Parent:

Thank you for choosing Creative Home Academy and Preschool, LLC. We are honored that you have chosen for us to help you in providing excellent care and foundational academic training. We do not take our responsibilities lightly and will do everything possible to ensure that your experience here is positive. Our childcare program is dedicated, loving, and well-trained. We look forward to greeting your child each day and teaching them valuable skills they will need to be successful in school. Socially, emotionally, and academically we strive to implement our core values and our curriculum program into every activity. We always welcome your presence and encourage you to come and watch us in action. Enclosed is a valuable packet of information as well as your registration forms. Once you have confirmed your decision on Creative Home Academy and Preschool, LLC, we ask that you complete all of the required forms and secure all necessary documentation. You will submit your completed form. We cannot accept a partially completed packet and therefore ask that you complete everything before submitting it. After your packet is submitted and checked by our office staff, you may set up your payment options with us. You will be placed on our mailing and email lists in order to receive updates throughout the fiscal year. We look forward to being part of your child's early childhood experience!

Creative Regards,
Mrs. Constance Sholar Cherry, B.A., C.D.A.

Child's Application

Full Name of Child:(Required)

Date of Admission:(Required)

Child's Date of Birth:(Required)

Name the child goes by:(Required)

Is the child related to the primary caregiver?(Required)

Yes

If yes, relationship to primary caregiver?(Required)

Child's School (if applicable):

Name

Address

Phone

Are the child's immunization records housed at the above school:(Required)

Yes

If no, list where they are housed:

Name

Address

Phone

Name of Agency:

Agency Address:

Street Address City State ZIP Code

Parents/Custodial Parents:

Mother's Name:(Required)

Father's Name:(Required)

Home Address:(Required)

Street Address City State ZIP Code

Home Address:(Required)

Street Address City State ZIP Code

Home Phone:(Required)

Cell Phone:(Required)

Employment:(Required)

Work Address:(Required)

Street Address City State ZIP Code

Work Address:(Required)

Street Address City State ZIP Code

Work Phone:(Required)

Work Hours:(Required)

Transportation Plan:

Please list any other adults to whom your child may be released or are authorized to provide transportation for your child.(Required)

Will the child be transported by the agency?(Required)

Yes

If yes, check all that apply:

To school

From School

To Home

From Home

Field trips only - with prior written permission for each off-site activity

Emergency Contact Information:

1. Name of person, other than the child care provider, authorized to act for parent in an emergency:(Required)

Home Address:(Required)

Street Address City State ZIP Code

Home Phone:(Required)

Place of Employment/School:(Required)

Address of Employment/School:(Required)

Street Address City State ZIP Code

Work Phone:(Required)

Work Hours:(Required)

Alternate Phone Numbers (cell):(Required)

2. Name of person, other than the child care provider, authorized to act for parent in an emergency:

Home Address:

Street Address City State ZIP Code

Home Phone:

Place of Employment/School:

Address of Employment/School:

Street Address City State ZIP Code

Work Phone:

Work Hours:

Alternate Phone Numbers (cell):

3. Name of person, other than the child care provider, authorized to act for parent in an emergency:

Home Address:

Street Address City State ZIP Code

Home Phone:

Place of Employment/School:

Address of Employment/School:

Street Address City State ZIP Code

Work Phone:

Work Hours:

Alternate Phone Numbers (cell):

Physician Contact Information:

Name of Physician:(Required)

Phone:(Required)

Address:(Required)

Street Address City State ZIP Code

Background Information:

Other Children In the Family:(Required)

Name

Date of Birth

School

(please use the + sign to add more if needed)

Experiences with Others:

What are some ways the child plays at home?(Required)

Does he/she play with children from other families?(Required)

How?(Required)

Does he/she react when he/she does not get his/her own way?(Required)

Is the entire family together for any time during the day?(Required)

Eating Habits:

At what time does the child eat breakfast?(Required)

Lunch?(Required)

Dinner?(Required)

Between meal snacks?(Required)

Does the child feed him/herself?(Required)

What is the child's general attitude toward eating?(Required)

If the child refuses to eat, how is this handled and by whom?(Required)

Food Favorites:(Required)

Food Dislikes:(Required)

Food Allergies:(Required)

Sleep Habits:

Has own room:(Required)

Yes

Shares room with:

Other Children

Parents

At night sleeps from:(Required)

At night sleeps to:(Required)

Average Hours of Sleep Per Night:(Required)

Naps From:(Required)

Naps To:(Required)

Average Hours of Naps:(Required)

Attitude toward going to bed?(Required)

If there is difficulty, how is this handled?(Required)

Habits associated with going to bed?(Required)

Is bed wetting an issue?(Required)

At nap time?(Required)

At night?(Required)

If yes, how is the situation handled?(Required)

Toilet Habits:

Time at which child is taken to the bathroom?(Required)

Can the child take themselves?(Required)

Time of bowel movement?(Required)

Regular?(Required)

Constipated?(Required)

Does the child tell you when he/she needs to go and does he/she go willingly?(Required)

Can he/she manage his/her clothes at the toilet?(Required)

What word does he/she use for urinating?(Required)

What word does he/she use for bowel movement?(Required)

Speech and physical Growth:

The child talks:(Required)

Well

Fairly Well

Not Very Well

Not at All

Does anyone read to the child?(Required)

Yes

How regularly?

At what age did the child creep?(Required)

At what age did the child crawl?(Required)

At what age did the child walk?(Required)

Which of the following words would you use to describe the child (check all that apply):(Required)

Is there any other information you think we should have about the child?(Required)

Ongoing Medical Care:

Does the child have any medical diagnosis that requires ongoing care?(Required)

Yes

If yes, please explain what type of care is administered at home and by whom?

Are you requesting that this care be provided at the facility?(Required)

Yes

If yes, describe the care required:

(Request a doctor's statement for any specific requests for care at the facility)

Parent Declarations:

Pre-enrollment Visit Date:(Required)

Signature of Parent(s)/Guardian(s):(Required)

Date:(Required)

Date of Child's Withdrawal:

Reason for Withdrawal:

This form/information shall be maintained for one year after date of disenrollment.

Information on this form shall be updated annually or as needed to ensure the protection of the child.

Date of last update with Parent's initials:

Child's Health History Checklist

Child's Name:(Required)

Birth Date:(Required)

Parent or Guardian's Name:(Required)

The answer to these questions will help us to know if your child has any medical problems. We need this information in case he/she should become ill and we are unable to reach you right away. Please select the right answer. We will go over the checklist with you when you have finished.

Pregnancy and Birth

1. Were there any problems with pregnancy or your child's birth?(Required)

Yes

2. Was his/her birth weight under 5½ pounds?(Required)

Yes

3. Did the baby have any problems in the hospital?(Required)

Yes

Medical Problems

4. Has your child ever been in the hospital overnight?(Required)

Yes

5. Is your child taking any medicine?(Required)

Yes

6. Any allergies or reactions to medicine, DTP or other shots or insects?(Required)

Yes

7. Has your child had asthma or wheezing?(Required)

Yes

8. Does your child have a speech or hearing problem?(Required)

Yes

9. Has your child had more than two ear infections in a year?(Required)

Yes

10. Has your child had tonsillitis?(Required)

Yes

11. Does your child have trouble with his/her eyes or seeing?(Required)

Yes

12. Has your child had a bladder or kidney infection?(Required)

Yes

13. Does he/she have burning when urinating?(Required)

Yes

14. Does he/she have seizures, fits to shaking spells?(Required)

Yes

15. Have you ever seen your child has a heart murmur?(Required)

Yes

16. Is your child able to play as hard as other children?(Required)

Yes

17. Has your child ever had a bumpy, swollen reaction to the TB skin test?(Required)

Yes

18. Has your child ever been with anyone having TB?(Required)

Yes

19. Has your child ever had worms?(Required)

Yes

20. Does your child scratch his/her genitals?(Required)

Yes

21. Are his/her genitals red or sore?(Required)

Yes

22. Is your child a hemophilia (free bleeder)?(Required)

Yes

23. Is your child on a heart monitor?(Required)

Yes

24. Does your child have tubes in his/her ears?(Required)

Yes

Older Girls

25. How old was your daughter when she had her first period?(Required)

Yes

26. Does she have any problems with her period?(Required)

Yes

General Development

27. Is your child in a special education class at school?(Required)

Yes

28. Does your child get along with other children?(Required)

Yes

29. Is he/she usually happy?(Required)

Yes

30. Does your child have any special problems not indicated above?(Required)

Yes

31. When did your child last see a doctor?(Required)

Yes

Month:(Required)

Year:(Required)

Parent/Provider Contract

Child/ren:(Required)

Policies and Procedures discussed with the provider:

Parent Signature:(Required)

Date:(Required)

Parent Signature:(Required)

Date:(Required)

Permission to Photograph

(Parent or Guardian's name)

Give permission for

(Creative Home Academy and Preschool, LLC)

To photograph my child,

(Child's Name)

For the following purposes:

Still Photographs: Display on daycare bulleting boards, show to current and prospective clients

Grant Permission

Decline Permission

Still Photographs: Display still photos on daycare website

Grant Permission

Decline Permission

Videos: Show to current clients

Grant Permission

Decline Permission

Signed:(Required)

(Parent or Guardian Signature)

Date:(Required)

Rates & Fees

This agreement contains the financial terms for childcare for the following child(ren):

which are agreed between Creative Home Academy and Constance Sholar Cherry, and their parent(s)/legal guardian(s):

The hours and days agreed upon for care are as follows:

Sunday

From (AM/PM)

To (AM/PM)

Monday

From (AM/PM)

To (AM/PM)

Tuesday

From (AM/PM)

To (AM/PM)

Wednesday

From (AM/PM)

To (AM/PM)

Thursday

From (AM/PM)

To (AM/PM)

Friday

From (AM/PM)

To (AM/PM)

Saturday

From (AM/PM)

To (AM/PM)

Notifications must be made, in writing, if any changes are needed to these hours. Two weeks notice is required for permanent changes in schedule. Parents agree to pay childcare according to schedule.

Parent(s)/Legal Guardian(s) have agreed to pay $

per

every (text entered below) for childcare.

Payments may be made in either cash or check. Please be advised there is a $45 charge for all returned checks. You will also be responsible for fees.

Parent/Guardian's Signature:(Required)

Date:(Required)

Childcare Provider's Signature: Date:

Basic Release

FOR MY CHILD:(Required)

This release allows (Creative Home Academy and Preschool, LLC) or her appointed substitute to administer CPG if needed.

It also allows them to apply the following non-prescription items to:

Diaper Rash Ointment or Cream
Sunscreen
First Aid Creams
Burn Creams
AS NEEDED.

Other:

Prescription medications will be administered at the discretion of (Creative Home Academy and Preschool, LLC) on an individual basis and must be in original containers. If your child is under two years of age the medication must be accompanied by a doctor's note. A medication log will be used for this, and kept in your child's file.

This release also releases the daycare and persons as stated above from any liability from any accident or injury which may occur regarding the above.

Parent Signature:(Required)

Provider Signature:

Influenza Information Notification Form

PUBLIC CHAPTER 687 requires the Department of Human Services and the Department of Health to work together to educate parents of children in child care agencies regarding the important of immunizing their children against influenza. The Department of Human Services works with child care agencies to ensure that this information is distributed annually to parents in August and September.

Signature of Parent or Legal Guardian:(Required)

Date(Required)

Signature of Parent or Legal Guardian:(Required)

Date(Required)

Signature of Agency Representative: Date:

Personal Safety Curriculum Notification

Since 1985, Tennessee law has required that children in child care agencies receive annual instruction in personal safety, including child sexual abuse prevention. The personal safety curriculum shall include a Tennessee Department of Human Services (TDHS) recognized component on the prevention of child abuse.

Public Chapter 1032 passed by the General Assembly in 2008 requires that child care agencies have a personal safety curriculum, including a child sexual abuse component, for children enrolled in the agency, and that parents/legal guardians be informed about the curriculum, methods and terminology that will be used in teaching children about personal safety. TDHS was directed to provide guidelines for this curriculum, but individual child care agencies may choose a curriculum that accomplishes the same goal, and may use different terminology in the curriculum. The child care agency is required to allow parents/legal guardians to review and ask questions about the curriculum, and to meet with representatives of the child care agency if they have questions.

In addition, the child care agency must obtain from parents/legal guardians a form acknowledging that they have been notified of the child sexual abuse/personal safety curriculum being used by the child care agency in which the child is enrolled. A copy of the form is required to be maintained in the child's record.

"Keeping Kids Safe" is the sample personal safety curriculum offered by TDHS. This curriculum takes a holistic approach to the safety of children. The curriculum is composed of the following units: Self Esteem, Family & Friends, Feelings, Problem Solving, Personal Safety (general) and Personal Safety (four to five (4- 5) year olds), and Safety Around Me. All sessions begin with group time and are followed by supplemental activities that give children additional practice in understanding the concepts. The curriculum uses hand puppets to serve as a group motivator and to introduce the stories. Together staff and parents decide what terminology to use when referring to the genitals, either the correct anatomical terms or the general term "private body parts" as specified below.

Child care agencies, please provide an answer for the questions that follow.

1. Identify the personal safety curriculum used by your agency:
☐ "Keeping Kids Safe" is the personal safety curriculum used by our child care agency.
☐ Our agency uses another personal safety curriculum described below:

Method of Instruction:

2. For all personal safety curriculum, please provide the sample anatomical terminology to be used:

Sample Terminology:

The instructional materials used in the agency personal safety curriculum are available for review by the parents or legal guardians.

Signature of Parent or Legal Guardian(Required)

Date(Required)

Signature of Parent or Legal Guardian(Required)

Date(Required)

Signature of Agency representative: Date:

Some childcare providers use the "Keeping Kids Safe" personal safety curriculum. The bottom portion of this section lists the web address where you can find this sample curriculum, provided by TDHS. Please bookmark the link so that you can review the curriculum at your leisure.
http://www.tn.gov/assets/entities/humanservices/attachments/keeping_kids_safe_content_updated_wdraft_cover.pdf

Infant Feeding Plan

Instructions: If you do not care for infants 12 months or younger, simply mark N/A on the form and submit.

Date:(Required)

Does this child take bottle?

Yes

Is the bottle warmed?

Yes

Does the child hold the bottle?

Yes

Can the child feed self?

Yes

Does the child eat: (check all that apply)

Strained Foods

Whole Milk

Baby Foods

Table Foods

Formula

Breast milk

Other

If other, please explain:

If formula is fed, what type of formula is used?

Amount of breast milk or formula given:

Updated Amount Date:
Updated Amount Date:
Updated Amount Date:

Does your child use a pacifier?

Yes

If yes, when?

Food Likes:

Food Dislikes:

Allergies:

Infants Schedule
Time Type and amount of food

Breakfast:

Snack:

Lunch:

Snack:

Dinner:

Snack:

Instructions for the introduction of solid foods:

Any additional/updated instructions regarding adding new foods or other dietary changes:

Enrollment Form

Child's Application

Child's Health History Checklist

Parent/Provider Contract

Permission to Photograph

Rates & Fees

Basic Release

Influenza Information Notification Form

Personal Safety Curriculum Notification

Infant Feeding Plan

Location 1 (Semmes Street)

Location 2 (Dunn Ave)

Have Questions?

Location 1 (Semmes Street)

Location 2 (Dunn Ave)