New Family and Student Registration Form New Family and Student Registration Contact InformationAre you enrolling more than one child?* YES NO Enrollment (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 AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest 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 #1 Participation in Fundraising Part 1*We do annual fundraising to support our mission of increasing quality early care and education in the entire Spokane area as well as to support the Community Building Children's Center. Select All Got it! I'm excited! I'd like to help out! Please tell me more! Participation in Fundraising Part 2*Would you or your employer be interested in supporting a fundraising event with a donation or sponsorship? YES NO MAYBE Parent or Guardian #2*Is there a second parent or guardian? YES NO Parent 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*Would you or your employer be interested in supporting a fundraising event with a donation or sponsorship? YES NO MAYBE Pick 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). Hours : Minutes AM PM 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.) Hours : Minutes AM PM 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 and invoices are emailed to the email address(es) provided. Payment is due by the 10th of each month (or the weekday following the 10th if it falls on a Saturday, Sunday, or Holiday). Payment may be made by ACH transaction from the link provided in the emailed invoice. Personal checks or bank checks made out to Community Building Children's Center or CBCC can be mailed to the address on the invoice. Payments mailed directly from your bank are also accepted. We do not accept credit cards for tuition payments. We do not accept cash for tuition payments. 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 10th calendar day of each month. Enrollment for your child(ren) may be terminated if payment for tuition is not received in 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 advance notice is requested before withdrawing your child from the program. A registration fee of $200 is required upon enrollment and $100 annually thereafter. A discount of 10% of the oldest child's tuition will be applied for families with multiple children enrolled simultaneously.* YES Working Connections Child Care Subsidy*We are enrolled in Working Connections. Please bill DSHS accordingly for our tuition costs. YES NO Billing 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* YES Family 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* YES Tell 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 Select files Accepted file types: jpg, png, Max. file size: 32 MB, Max. files: 4. 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 AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest 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)* Month Day Year Current Age (1)*Please enter a number from 0 to 7.Group Care (1)*Has this child been in group care before? YES NO Please describe the prior experience with group care: (1)Naps (1)*Does this child take naps? YES NO SOMETIMES How long are the naps and at what time of day? (1)* Toilet Training (1)*Is this child toilet trained? YES NO NEEDS ASSISTANCE Child's Health History (1)Date of last well baby or child exam: (1)* 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, Max. file size: 32 MB.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? YES NO Allergy Reaction Plan & Medication Orders (1)*Accepted file types: jpg, pdf, Max. file size: 32 MB.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? YES NO Frequency 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)HiddenPermissions*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.* Yes No Community Building Children's Center has my permission to take photographs/video of my child for documentation, assessment, and training purposes.* Yes No Community Building Children's Center has my permission to take my child on walks.* Yes No Treatment 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.* YES NO Child'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)* Month Day Year Age of Student (2)*Please enter a number from 0 to 7.Group Care (2)*Has this child been in group care before? YES NO Please describe the prior experience with group care: (2)Naps (2)*Does this child take naps? YES NO SOMETIMES How long are the naps and at what time of day? (2)* Toilet Training (2)*Is this child toilet trained? YES NO NEEDS ASSISTANCE Child's Health History (2)Date of last well baby or child exam: (2)* 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, Max. file size: 32 MB.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, Max. file size: 32 MB.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? YES NO Frequency 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)HiddenPermissions*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.* Yes No Community Building Children's Center has my permission to take photographs/video of my child for documentation, assessment, and training purposes.* Yes No Community Building Children's Center has my permission to take my child on walks.* Yes No Treatment 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.* YES NO