Test page - Wee Wisdom - Nursery School & Child Care Center

Enrollment Application

Step 1 of 22

Enrollment Date*
(First Day of Attendance)
Legal Guardian #1*
First Last
Legal Guardian #2
First Last
Child's Information
Name*
First Middle Last Suffix
(As it appears on birth certificate)
Date of Birth*
Current Age:*
Years Months
Height (in Inches):*
Weight (in Pounds):*
Address*
Street Address Address Line 2 City State ZIP Code
The Above Child Resides With:*
- Mother & Father
- Mother
- Father
- Other
Name:*
Relationship to Child:*

Siblings Living at Home with Child:

Name	Age

Click on the "+" symbol to add additional children.

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Parent Volunteer Form
Child's Name:*
First Middle Last
Parent Sign-Up
Halloween Party (October)*
Please check all that apply.
I am willing to serve as a Chairperson
I am willing to serve as a Committee Member
Easter Party/Treasure Hunt (Spring)*
Please check all that apply.
I am willing to serve as a Chairperson
I am willing to serve as a Committee Member
Thank you for volunteering to help with our parties! Your participation will help make our parties special! Your time and efforts are very much appreciated!
Signature*

Date Submitted:*

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Special Dietary Needs/Requirements
Child's Name*
First Middle Last
Special Dietary Needs/Requirments*
My child does not have special dietary needs/requirements. Please sign and date the bottom of this page.
My child DOES have special dietary needs/requirements based on medical reasons as described below: (PLEASE NOT: IN ADDITION TO A PARENT DESCRIPTION OF THE MEDICAL ISSUE BELOW, THE PARENT MUST ALSO PROVIDE A STATEMENT FROM THE DOCTOR, COMPLETE WITH A LIST OF SUBSTITUTIONS THAT ARE APPROPRIATE FROM THE DOCTOR'S STANDPOINT.)
My child does have special dietary needs/requirements, based upon our family's religious or personal beliefs.
Special Dietary Needs Acknowledgement:*
I have read Wee Wisdom's policies and "Special dietary needs", food allergies, physical examination requirements, "special needs enrollees", and "inclusion policies".
I have discussed these policies with my child's physician, and my child's physician agrees with me that Wee Wisdom's environment and methods of intervention related to my child's dietary needs will be "medically safe and free from potentially hazardous risks."
NOTE: If a food allergy is present, Wee Wisdom reserves the right to request that parents furnish all foods for their child(ren). If this applies, please read/sign below.
Parents Description of Special Dietary Needs:*
Parents Suggestions For Providing Substitutions:*
Description of special dietary needs/requirements based upon religious or personal beliefs:*
NOTE: If a food allergy is present, Wee Wisdom reserves the right to request that parents furnish all foods for their child(ren). If this applies, please read/sign below.
Food Transportation Agreement
SAFE TRANSPORTATION OF FOOD RESPONSIBILITY

Food must be brought to the center in clean, insulated, and sanitized containers, which keeps cold food at 41 degrees F., or below and hot food at 135 degrees F., or above.
Upon receiving the food fro the parent, the center shall verify the temperature of the food. When potentially hazardous food temperature is not correct, the center WILL NOT ACCEPT THE FOOD.
Due to medical reasons documented and attached from my child's physician, I, parent of the student listed at the top of this page, will provide food for my child on a daily basis. As the parents, I take full responsibility for the safety of food preparation, the selection of the food, the storage and transport of the food to Wee Wisdom.
Since I am providing food for my child to eat each day, I assume full responsibility for the nutritional needs of my child.
Full Parent Name:*

Signature*

Date Submitted:*

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Child's Name:*
First Middle Last
Are you wanting to register for Nursery School?*

Yes

No
Nursery School Selection
I would like my child registered for:*

Friday Toddler Class - 9:00 -10:25 am

T/TH Classes - 8:30 -10:20 am

T/TH Classes - 10:30 -12:20 pm

M/W/F Classes - 8:30 -11:20 am

M/W/F Classes - 12:30 -3:20 pm

Pre-K Classes - 8:00 -10:55 am

Pre-K Classes - 12:00- 2:55 pm

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Child's Name:*
First Middle Last
Are you wanting to register for Child Care?*

Yes

No
Child Care Choice: August-May
I would like my child under the following child care choice:*
(August-May)

#1 Weekly

#2 Daily

#3 Half-Day

#4 After School

#5 Before School

#6 Social Hour
Which day(s) of the week will your child be attending?*
Check all that apply
Monday
Tuesday
Wednesday
Thursday
Friday
What time will your child be staying with us?*
Please list in a four (4) hour block. For example: Monday 11a-3p.
Day of Week Hours

One Child, August - May*

2 year old

3, 4, 5 year olds
Do you need summer child care?*

Yes

No
Child Care: Summer
I would like my child under the following child care choice:*
(Summer)

#1 Weekly

#2 Daily

#3 Half-Day

#6 Social Hour
Which day(s) of the week will your child be attending?*
Check all that apply
Monday
Tuesday
Wednesday
Thursday
Friday
What time will your child be staying with us?*
Please list in a four (4) hour block. For example: Monday 11a-3p.
Day of Week Hours

One Child, June-July (Summer)*

2 year old

3, 4, 5 year olds

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Transportation Needs K-6
Child's Name:*
First Middle Last
Transportation Needs:*

My child will not require Wee Wisdom transportation either to or from school.

My child will require Wee Wisdom transportation as listed:
To School:
Name of School

From School:
Name of School

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Payment Options
If your child attends nursery school exclusively, payments are due monthly on the first of each month.
If your child attends nursery school and child care, you have three options for payment:

Weekly: Payment due on or before Friday of each week or the last day child is scheduled to attend each week.

Bi-Weekly: Payment due on or before Friday of each week or the last day child is scheduled to attend each week. You must pay 1 week in arrears and 1 week in advance.

Monthly: You will be billed the third week of every month for the upcoming month Payments due on or before the 1st of each month in advance of services.
My child is enrolled in:*

Nursery School Only

Nursery School/ Child Care Combination

Child Card Only (School Age K-6 & Summer CC)
I would like my payment options to be:*

Weekly

Bi-Weekly

Monthly
My payment options is:*

Monthly

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Security System Agreement: Use of Key FOBS
Student Name:*
First Middle Last
Description of Agreement*
Please read each item and select box to indicate that you understand and will abide by these rules.
1. I understand that each person listed on my child's authorization of pick up list much have their own key fob at all times when arriving to drop off and pick up.
2. Sharing Key Fobs among authorized/unauthorized users is not permitted.
3. No one will be permitted to enter the building without an authorized Key Fob or prior approval from the office, which will require picture ID.
4. Authorized users may still be required to show picture ID upon arrival to pick up children. If we do not recognize someone entering our building, even if they possess a key fob, picture ID will still be required.
5. Only individuals listed on your authorization of pick up list will be permitted to leave the building with your child. If you need to add or delete individuals from this list at any time, it is the parent's responsibility to keep the list current with the main office.
6. If you delete someone from your authorization list, you must return the key fob assigned to that individual immediately to avoid a lost or stolen key fob fee of 25.00. Upon the timely return of the Key Fob, you will be given a credit of 10.00 for each key fob returned.
7. If you need to add someone to your authorization list, you must come to the office and meet Kathy. She will give you an additional key fob upon receipt of your 10.00 deposit. The new key fob will be assigned by number to the new person that you have added.
8. Upon entering the vestibule, you must wait for anyone who is attempting to enter to complete their entry and for the door to close again. DO NOT ATTEMPT TO ENTER WITHOUT USING YOUR OWN KEY FOB AND WAITING FOR THE DOOR TO OPEN IN RESPONSE TO YOUR "ENTRY". (IE., DON'T PIGGY- BACK INSIDE ON SOMEONE ELSE'S ENTRY)
9. Keep you Key Fob on your Key Ring. When entering the vestibule, touch the reader with the fob. It will read your number, and the door will automatically unlock for you to enter.
10. If you need to add someone to your authorization list as an emergency, call the office in advance to announce that you are sending someone that is not on your list. You will automatically be assessed an additions $10.00 fee for an additional key fob. It is your responsibility to inform all authorized persons (even those that you may add in an emergency situation) that they must always bring their picture id into the vestibule with them. Anyone who attempts to enter must show their picture ID to the camera in the vestibule. We will check the id from the office over the screen and based on our advance knowledge of that person's arrival, we will unlock the door and allow them to enter.
11. If you lose a key fob, you will be charged an additional fee of 25.00 and you will also lose your down-payment of 10.00 for each key fob not returned or each key fob reported as lost or stolen. In addition, you will need to pay another $10.00 deposit on any new key fob issued.
12. When you withdraw from Wee Wisdom, your account will be credited 10.00 for each key fob that you return on or before the last day of attendance.
13. Wee Wisdom will be on "lock-down" all day every day.
14. I understand that if addendum's are made to this agreement, parents will receive a copy of these changes in writing.
15. Key Fobs are issued and returned only through the main office administration.
Signature:*

Date Submitted:*

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Insurance Information
Student's Name:*
First Middle Last Suffix
Date of Birth:*
Insurance Coverage:*
CURRENT INFORMATION ABOUT YOUR CHILD'S HEALTH INSURANCE COVERAGE IS REQUIRED FOR TREATMENT IN AN EMERGENCY:

My child DOES HAVE insurance coverage at this time

My child DOES NOT HAVE insurance coverage at this time.

My child is covered by Medicaid.
Insurance Carrier: (Company)*

Policy Number:*

Name of Insured:*
(Example: If the policy is carried by the father, list the father's full name."
First Last
Relationship to above student:*

In the case of a medical or dental emergency, Wee Wisdom has identified IU Health/Ball Memorial Hospital as the "facility of intent" for emergency services that may be needed.
On Enrollment Form E-4, the parents/guardians of all enrollees have signed consent for emergency treatment and trasnsport to IU Health Ball Memorial Hospital IF NEEDED. This form has been notarized and is on file to use in the event of an emergency that requires immediate medical or dental attention.

INDIVIDUAL EMERGENCY CARE PLAN FOR THE ABOVE STUDENT:
Please list and describe any known medical or developmental problem or other conditions that might require special care in an emergency. [Examples include, but are not limited to: Allergies (environmental, food, medication, other); Asthma, Seizures; Orthopedic or Sensory Problems; and other Chronic Conditions, including conditions that require regular medication or technology support.]

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Family Album
Hello! My Name is:*
First Middle Last Suffix
I live with:*

I have pets at my house. They are:*
In my house, we speak the following language(s):

My family is from:

United States of America (USA)

My family and I like the following foods:
Our favorite holidays and celebrations are:
(Please describe.)
Some of our family customs include:
(Please describe.)

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Family Pictures & Descriptions
Please upload pictures that your child can share with the class. Pictures may include family members, pets, family vacations, customs, celebrations, etc.
Photo #1
Max. file size: 32 MB.
Please write a description for photo #1.
Photo #2
Max. file size: 32 MB.
Please write a description for photo #2.
Photo #3
Max. file size: 32 MB.
Please write a description for photo #3.
Photo #4
Max. file size: 32 MB.
Please write a description for photo #4.

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Full Name (First/Middle/Last)	Relationship to Child	Daytime Phone	Other Phone

Doctor's Name	Office Address (Address, City, Zip)	Office Phone

Enrollment Application

Step 1 of 22

Child's Information

Parents' Information

Contact Information

Emergency Contacts

Authorization of Pickup

About My Child

Communication

Eating & Drinking

Toileting:

Fine-Motor Activities

Gross Motor Skills

Resting & Napping

Playing with Others

Additional Behavior Information:

Intake Agreement

State Licensing Law: Public Law 12

Prohibited Items at Wee Wisdom

Agreement/Compliance Acknowledgement

Agreement/Compliance Acknowledgement (Continued)

Agreement/Compliance Acknowledgement (Continued)

Pool Use

TOILET TRAINING

Parent Volunteer Form

Parent Sign-Up

Special Dietary Needs/Requirements

Food Transportation Agreement

SAFE TRANSPORTATION OF FOOD RESPONSIBILITY

Nursery School Selection

Child Care Choice: August-May

Child Care: Summer

Transportation Needs K-6

Payment Options

Security System Agreement: Use of Key FOBS

Insurance Information

Family Album

Family Pictures & Descriptions

Paths to QualityIndiana’s Highest Ranking

State LicensedChild Care Center

Nationally Accreditedthrough NAEYC

On My WayPre-K

CCDF VouchersAccepted

Paths to Quality
Indiana’s Highest Ranking

State Licensed
Child Care Center

Nationally Accredited
through NAEYC

On My Way
Pre-K

CCDF Vouchers
Accepted