New Family and Student Registration Form New Family and Student Registration Contact InformationAre you enrolling more than one child?*YESNOEnrollment (1)*Child's NameChild's BirthdateClassroom (Toddler or Preschool)# of Days per WeekEnrollment (2)Child's NameChild's BirthdateClassroom (Toddler or Preschool)# of Days per WeekParent or Guardian Name #1* First Last Mailing Address #1* Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Email #1* Enter Email Confirm Email Phone #1 Personal*Phone #1 Work*Employer #1*Job Title #1Participation in Fundraising Part 1*Our annual fundraising event, The Great Spokane Art Party, is held the last Saturday in April. This is a community building event as much as it is a fundraiser. Families, Staff, and Board all participate to sell event tickets and raffle tickets, provide food and wine, and volunteer the day of the event. There are also opportunities to serve on the GSAP Committee. Select All Got it! I'm excited! Please tell me more! I'd like to help out! I've never been to the event, so may need some help getting up to speed. Participation in Fundraising Part 2*Would you or your employer be interested in supporting this event with a donation or sponsorship?YESNOMAYBEParent or Guardian #2*Is there a second parent or guardian?YESNOParent or Guardian Name #2* First Last Email #2* Enter Email Confirm Email Mailing Address #2 (IF DIFFERENT THAN ADDRESS #1) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone #2 Personal*Phone #2 Work*Employer #2*Job Title #2*Participation in Fundraising (#2) Part 2*Our annual fundraising event, The Great Spokane Art Party, is in April. Would you or your employer be interested in supporting this event with a donation or sponsorship?YESNOMAYBEPick up and Drop Off*Who will be bringing and picking up the child(ren) to and from the center each day? Please include yourself and list individuals in order of frequency. You may add up to five individuals, just click on the plus sign at the end of each row to add another row. NameRelationship to ChildContact Phone # Typical Drop-Off Time*Please let us know what time your child(ren) will be dropped off each day. We prefer that it is no later than 9:30 (we open at 7:30). HH : MM AM PM Typical Pick-Up Time*Please let us know what time your child(ren) will be picked up each day. We prefer that it is no earlier than 3:15. (We close at 5:30. There is a fee of $1/minute for every minute after 5:30 that the child(ren) are not picked up.) HH : MM AM PM Emergency Contacts*Please list up to five individuals, just click on the plus sign at the end of each row to add another row. NameRelationship to ChildContact Phone #Email Billing, Tuition, and Center AgreementsTuition Payments : I understand that: Tuition is billed monthly on or before the 1st of the month. Invoices are sent by email. Payment is due by the 5th of each month (or the weekday following the 5th if it falls on a Saturday, Sunday, or Holiday). Payment may be made by personal check or bank check. If you are bringing payment, it can be deposited into the lockbox in the preschool classroom. Payments mailed directly from your bank are also accepted. We do not accept credit cards for tuition payment on a regular basis. Cash payments for tuition must be made in person so that we may provide a receipt. If you have concerns about making a payment or would like to request an altered payment schedule, please contact us to discuss your needs. A late fee of $25 may apply if tuition is received after the 5th calendar day of each month. Enrollment for your child may be terminated if you do not pay your bill within the month it is due, unless you have made other arrangements with the Center Director. Families will be invoiced late fees of $1/minute for each minute past 5:30 on any day that their child(ren) are picked up past 5:30 pm. Credit is not provided for missed days. If additional days are needed on an occasional basis and if there is space available in the classroom, these days will be added to the monthly invoice. See our tuition rates for pricing. Two weeks notice is required before withdrawing your child(ren) from care. Families will be charged $42 each trimester (January, May, September) for Music Together take home materials. A registration fee of $100 is required upon enrollment and annually thereafter. A discount of 10% of the oldest child's tuition will be applied for families with multiple children enrolled simultaneously.*YESWorking Connections Child Care Subsidy*We are enrolled in Working Connections. Please bill DSHS accordingly for our tuition costs.YESNOBilling address*Which address should we use for billing? Monthly invoices and receipts are sent by email. Mailing Address 1 Malling Address 2 Email 1 Email 2 Disaster Handbook: I have read the disaster handbook and understand Community Building Children's Center's protocols in the event of an emergency situation. This is available on the New Family and Student Registration Page of the website. https://blueprints4learning.org/wp-content/uploads/2018/05/CBCC-Disaster-Plan-5.18.pdf*YESFamily Handbook: I have read the Family Handbook. This is available on the New Family and Student Registration Page of the website. https://blueprints4learning.org/wp-content/uploads/2018/05/Parent-Handbook-2017.pdf*YESTell us about your Family and your Child(ren)Family*Please describe your family, including significant people that your child relates to:Traditions*What beliefs, traditions, or holidays are important to your family? What would you like us to know about them? Would you like to share them with the program? If so, how would you like to do that?Fears and Dislikes*Please tell us about any of your child(ren)'s fears or dislikes that you would like us to know about:Comfort*What is the best way to comfort your child(ren) if he/she is upset?Additional InformationWhat else would you like us to know about your child(ren) and your family?Family Photo(s)*Please upload one or more photos of your family, pets, and close extended family to put in your child's portfolio. We use these photos with your child to help calm and reassure them when they are missing you. Drop files here or Accepted file types: jpg, png. General Health InformationHealth Insurance Company*Subscriber Name*Policy Number*Child(ren)'s Physician or Preferred Provider*Phone # of Provider*Address of Provider Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Emergency Hospital Preference*Dental ProviderWho is your child's dentist?Child's Information (1)Child's Name (1)* First Last Nickname (1)If your child has a nickname, indicate it here.Birth Date (1)* MM DD YYYY Current Age (1)*Please enter a number from 0 to 7.Group Care (1)*Has this child been in group care before?YESNOPlease describe the prior experience with group care: (1)Naps (1)*Does this child take naps?YESNOSOMETIMESHow long are the naps and at what time of day? (1)*Toilet Training (1)*Is this child toilet trained?YESNONEEDS ASSISTANCEChild's Health History (1)Date of last well baby or child exam: (1)* Date Format: MM slash DD slash YYYY Exams (1)*Please indicate what health exams your child has had: Vision Hearing Dental Vision (1)When did this occur and what was the outcome of the vision test?Hearing (1)When did this occur and what was the outcome of the hearing test?Dental (1)When did this occur and what was the outcome of the dental exam?Immunization Record (1)*Create an account on MyIR.net to access your child’s immunization records. This takes about five minutes to complete. Once you have created your account, please download and/or print out the immunization record for each child enrolled in our program and upload the file here.Accepted file types: jpg, pdf.Allergens and Irritants (1)*For allergies of a serious nature that cause reactions involving hives or other potentially severe symptoms requiring the administration of medication or emergency medical response, a full Allergy Reaction Plan & Medication Orders are required from your health care provider.Allergen/IrritantIntoleranceAllergySubstitute (if applicable) Allergies (1)*Are any of the above life threatening?YESNOAllergy Reaction Plan & Medication Orders (1)*Accepted file types: jpg, pdf.Preferences (1)Please tell us what kinds of food your child is accustomed to eating. What does your child like? Dislike?Illnesses and Accidents (1)*Please list any illnesses (common to chronic) and serious accidents that you child has had and at what age. You can add rows by clicking on the plus sign at the end of each row.Illness or AccidentAge Temperament (1)*How does your child act when ill? (Cries, sleeps a lot, pulls on ears, etc.) Frequency of colds (1)*Does your child have frequent colds?YESNOFrequency Part 2 (1)*Tell us more about the type of colds and frequency.Health Concerns (1)*Please describe any other health concerns that our staff should be aware of:Authorizations (1)Permissions*Community Building Children's Center has my permission to: Select All Take my child on walks Take photographs/video of my child for documentation, assessment, and training Give my phone number and email to enrolled families Community Building Children's Center has my permission to give my phone number and email to other enrolled families.*YesNoCommunity Building Children's Center has my permission to take photographs/video of my child for documentation, assessment, and training purposes.*YesNoCommunity Building Children's Center has my permission to take my child on walks.*YesNoTreatment Authorization: I hereby give my permission that my child, named above on this form, may be given emergency treatment to include first aid and CPR by a qualified child care provider at Community Building Children's Center. When I cannot be contacted, I authorize and consent to medical and hospital care, treatment, and procedures for surgery, to be performed for my child by a licensed physician, health care provider, hospital, or EMT when deemed necessary or advisable to safeguard my child's health. I waive my right of informed consent to such treatment. I also give my permission for my child to be transported by ambulance or aid car to an emergency center for treatment.*YESNOChild's Information (2)Child's Name (2)* First Last Nickname (2)If your child has a nickname, indicate it here.Child's Birth Date (2)* MM DD YYYY Age of Student (2)*Please enter a number from 0 to 7.Group Care (2)*Has this child been in group care before?YESNOPlease describe the prior experience with group care: (2)Naps (2)*Does this child take naps?YESNOSOMETIMESHow long are the naps and at what time of day? (2)*Toilet Training (2)*Is this child toilet trained?YESNONEEDS ASSISTANCEChild's Health History (2)Date of last well baby or child exam: (2)* Date Format: MM slash DD slash YYYY Exams (2)*Please indicate what health exams your child has had: Vision Hearing Dental Vision (2)When did this occur and what was the outcome of the vision test?Hearing (2)When did this occur and what was the outcome of the hearing test?Dental (2)When did this occur and what was the outcome of the dental exam?Immunization Record (2)*Create an account on MyIR.net to access your child’s immunization records. This takes about five minutes to complete. Once you have created your account, please download and/or print out the immunization record for each child enrolled in our program and upload the file here.Accepted file types: jpg, pdf.Allergens and Irritants (2)*For allergies of a serious nature that cause reactions involving hives or other potentially sever symptoms requiring the administration of medication or emergency medical response, a full Allergy Reaction Plan & Medication Orders are required from your health care provider.Allergen/IrritantIntoleranceAllergySubstitute (if applicable) Allergies (2)*Are any of the above life threatening? YES NO Allergy Reaction Plan & Medication Orders (2)*Accepted file types: jpg, pdf.Preferences (2)Please tell us what kinds of food your child is accustomed to eating. What does your child like? Dislike?Illnesses and Accidents (2)*Please list any illnesses (common to chronic) and serious accidents that you child has had and at what age. You can add rows by clicking on the plus sign at the end of each row.Illness or AccidentAge Temperament (2)*How does your child act when ill? (Cries, sleeps a lot, pulls on ears, etc.) Frequency (2)*Does your child have frequent colds?YESNOFrequency Part 2 (2)*Tell us more about the type of colds and frequency.Health Concerns (2)*Please describe any other health concerns that our staff should be aware of:Authorizations (2)Permissions*Community Building Children's Center has my permission to: Select All Take my child on walks Take photographs/video of my child for documentation, assessment, and training Give my phone number and email to enrolled families Community Building Children's Center has my permission to give my phone number and email to other enrolled families.*YesNoCommunity Building Children's Center has my permission to take photographs/video of my child for documentation, assessment, and training purposes.*YesNoCommunity Building Children's Center has my permission to take my child on walks.*YesNoTreatment Authorization: I hereby give my permission that my child, named above on this form, may be given emergency treatment to include first aid and CPR by a qualified child care provider at Community Building Children's Center. When I cannot be contacted, I authorize and consent to medical and hospital care, treatment, and procedures for surgery, to be performed for my child by a licensed physician, health care provider, hospital, or EMT when deemed necessary or advisable to safeguard my child's health. I waive my right of informed consent to such treatment. I also give my permission for my child to be transported by ambulance or aid car to an emergency center for treatment.*YESNO