OFFICE USE-Cash/Check#: __________ Amount PD_____ # of children per family registering: ____
REGISTRATION FEES ARE NON-REFUNDABLE
OFFICE USE-AGE GROUP: ____TEACHER: _________________
Child’s Preferred Name: ___________________________________________ Birthdate: ___________________ Race: ________________ Male: ___________ Female: ___________
Primary contact: ___________________________________________Relationship: ______________________
Address ________________________________________________City: ___________________ Zip: ___________
Best Phone (______) ______________________ Work (_____) ________________________
E-mail address: ________________________________________________________________________________ Place of Employment/Occupation: ______________________________________________________________ Secondary contact: _________________________________________ Relationship: ____________________ Address ________________________________________________City: ___________________ Zip: ___________ Best Phone (______) ______________________ Work (_____) ________________________
E-mail address: _______________________________________________________________________________ Place of Employment/Occupation:_____________________________________________________________ Child lives with: both parents ___ mother ___ father ___ legal guardian___.
Requested Enrollment Days: _____ Mon-Fri. _____ Mon-Wed-Fri
_____ Tues-Thurs (Option only for Nursery 1-4)
Nursery 1 Enrollment: In which month will your child begin attending? _________________________
**A $25 fee will be assessed if child’s days attending is changed per parent request after the initial registration. I plan to use Extended Care: (this is just a general idea for staffing purposes, no commitment).
Mornings: __________ Afternoons: __________
In Case of Emergency Call: List by priority, the best contact and phone number. (Example: Contact #1-Mom, #2- Dad, #3- Grandparent, etc.)
1.Name: ______________________________ Phone: ____________________ Relationship: ______________ 2.Name: ______________________________ Phone: ____________________ Relationship: ______________ 3.Name: ______________________________ Phone: ____________________ Relationship: ______________ 4.Name: ______________________________ Phone: ____________________ Relationship: ______________
Additional people (other than emergency contacts listed above) who may pick up my child:
Name: ___________________________________Phone: ____________________Relationship: ______________ Name: ___________________________________Phone: ____________________Relationship: _______________ Name: __________________________________ Phone: ____________________Relationship: _______________
Has child been in a caregiver/daycare/preschool setting before? _____Yes _____ No
Where? _______________________________________________Dates: ____________________________
Reason for withdrawal? ___________________________________________________________________
Why did you choose the Homewood Day School? You may check more than one answer.
Returning Student _____Internet _____ Location _____ Member HCOC _____
Parent Referral _____ By whom? _________________________________
Is there anything special we need to know about your child? (Nicknames, unusual fears, etc.): __________________________________________________________________________________________
• Does your child receive outside services such as speech or physical therapy?
No_____ Yes ______ How often? ________________________ Where? ______________________________
The primary language spoken in your home: English_____ Spanish____ Other________________
Is your child potty-trained (3K-4K)? Yes _____ No _____ *must be potty trained by 1/2022
For our database, where do you worship? ________________________________ NA ______________ As a ministry of the Homewood Church of Christ, we are here to teach and show
God’s love to your precious children. Please know we welcome you and your family to the Homewood Church of Christ.
Medical Conditions: NA: ____ Yes: ______________________________________________________________ Treatment: _____________________________________________________________________________________ Allergies: NA: _____ FOOD: _____________________________ OTHER: ________________________________ Mild__ Moderate__ Severe___ Treatment: __________________________________________________ Does your child carry an Epi-pen? No _____ Yes ______
We must have a Medicine Release or Emergency Medicine Release form on file if your child requires medicine to be kept or administered at school.
• I understand that I am responsible for any tuition and fees incurred while my child is enrolled at the Homewood Day School. If I withdraw my child, I will submit notification of withdrawal in writing 30 days prior to withdrawal. I am responsible for all fees, tuition, and late fees until notification is submitted and the 30-day period is satisfied. Registration fees, yearly DHR exemption affidavit and a current immunization form are due before my child may begin school.
• The Day School reserves the right to de-enroll any child whose social, physical, or emotional needs are beyond the resources and training of our current staff.
• Emergency Authorization: In order to meet all legal requirements, I hereby authorize the Director, Assistant Director, or extended care coordinator of the Homewood Church of Christ Day School to give consent for any emergency medical care for my child while he/she is in custody of the Homewood Day School.
Scrapes and Cuts: I give permission for my child to have antibiotic ointment applied to scrapes and cuts.
Insect Stings: I give permission for my child to have anti-itch cream applies to insect stings.
• Children in Diapers: My child may have diaper rash ointment applied if needed. Parent/Guardian Signature: ____________________________________________________
COVID POLICY AND PROCEDURES HIGHLIGHTS:
Temperatures of employees and students will be taken before entering the building. If a staff member or child has a fever of 100 degrees or more, they will not be allowed entry and will not be able to return without a doctor’s note. If a child presents with a temperature of 99, he /she will be allowed to stay, and his/her temperature will be checked every 30 minutes. If his/her fever rises to 100, they will be taken out of the classroom and isolated with a staff member until the parent arrives.
Our sick policy will be 72 hours fever, vomit, and diarrhea free without medication or a doctor’s note saying they are safe to come back.
If a child or parent of a child has been “exposed” they will be asked to stay out of school up to 14 days before returning
If we are made aware that a child or parent of a child has tested positive for COVID-19, the child will be asked to stay home for up to 14 days. Additionally, the spaces that the child has occupied will be closed for 24 hours and disinfected before children can return to those spaces and we will then try to self-quarantine that class up to 14 days.
If a child or staff member have traveled out of the country, or to another state with high COVID-19 cases, they may be asked to stay out of school and self-quarantined for up to 14 days before returning to school.
No parents will be allowed in the school unless there is an emergency, and then when authorized by the Day School Administrative staff
I have read and agree to abide by the Parent contract and the COVID Policy and Procedures
Parent/Guardian Signature: ___________________________________________
FORM OF AFFIDAVIT FOR PARENT/GUARDIAN 2021-22
State of Alabama
County of Jefferson
Before me, a Notary Public in and for said State and County, appeared ____________________________________ and is known to me, after being duly sworn or affirmed, says as follows:
That affiant is the parent or legal guardian of the minor child/children _____________________________________; that affiant has been notified by Homewood Church of Christ Day School, that said church or school has filed notice and is exempt under law from regulation by the Department of Human Resources.
___________________________ Parent/Legal Guardian
Sworn, or affirmed to and subscribed before me this ___ day of _____________, 2021.
__________________________________ Notary Public My commission expires_______________.
This form is required to be kept on file per DHR exempt status requirements. Submit before the first day of school.
Child’s Medical Report (Rev.4/06) (This form may be used for household members younger than 19 years of age)
Child’s Name: _____________________________________________ Date: __________________________________
Name of child’s parent or guardian: __________________________________________________________________
Address: __________________________________________________________________________ Telephone Number: _______________
In addition to a medical report or medical screening, a Certificate of Immunization (ADPH-IMM-50) is required for each child 2 months to 5 years of age and for 5-year-olds who are not enrolled in public or private school.
History of Allergies: _________________________________________________________________________________________
I examined this child on (date) _____________________. I find him/her to be in good physical condition and free of contagious infectious diseases, except as noted below.
Signature of Physician, Physician’s Assistant, Certified Nurse Practitioner: