Fill - Free fillable Butler Educare Center Learning Lab Enrollment Packet School Age (Butler Community College) PDF form

Butler EduCare Center

Learning Lab

Enrollment Packet

Questions??

Please contact EduCare at (316) 323-6845

Dear Parents,

We would like to welcome you to Butler Community College EduCare Learning

Lab. We are excited you have chosen our center to be a vital role in your

child’s early years of exploration and development.

We believe strongly in creating an environment that assists in the development

of cognitive, language, physical, creative, and social/emotional skills that will

build a strong a foundation for your child/ren.

We take pride in being nationally accredited by the National Association for

the Education of your children. NAEYC is the nation’s leading voice for high

quality early childhood education birth through age eight.

Our commitment to you is to provide a loving, safe, and developmentally

appropriate environment that you feel safe leaving your child in when you are

away.

The paperwork and handbook you received provided you with information

about our policies and day-to day operations. The enrollment forms included

need to be completed prior to the first day of enrollment. Please complete

forms in their entirety and do not leave information blank. We are here to assist

you if you need help.

The administration and teachers would like to thank you for allowing us to be

part of your family and also welcome you to the EduCare family. We look

forward to many years of working together with you.

Sincerely,

Sue Barrientos-Administrator

Susan Duncan-Director

Brent Martin-Assistant Director

Butler Community College EduCare Center

Child Enrollment Record

Date of Application ______________ Start Date_______________________

Weekly Schedule ____________________________________________________________________________________

Child’s Name (First)___________ (Last)___________ (Middle)___________ Nickname_______________

Child’s Home Address (Street)____________________________(City)___________________(State)______________(Zip)_______

Phone _____________________ Date of Birth_______________ Age _____ Sex (Circle One)___ Female Male

Mother’s Name ____________________________________ Home Phone __________________________________

Home Address (Street)___________________________(City)___________________________(State)____________(Zip)_________

Business Name ______________________________________________Business Phone___________________________

Business Address (Street)___________________________(City)_________________________(State)___________(Zip)_________

Occupation_________________________________________________________________________________________

Cell # ______________________

E-Mail_____________________________________________________________________________________________

Father’s Name ______________________________________ Home Phone___________________________________

Home Address (Street)___________________________(City)____________________________(State)____________(Zip)________

Business Name ______________________________________________ Business Phone__________________________

Business Address (Street)___________________________(City)_________________________(State)____________(Zip)________

Occupation_________________________________________________________________________________________

Cell # ______________________

E-Mail_____________________________________________________________________________________________

Community Member______ DCF Client___________ Butler Student_______________ Foster Care______________

**Parents who are students must provide a copy of their student schedule each semester to receive student discount**

Family Home Situation

Marital Status of Parents: Married____ Divorced____ Separated____ Single____

Legal Custody of child: Both Parents____ Father____ Mother____ Other____

Child’s Living Arrangement: Both Parents____ Father____ Mother____ Other____

Custody Schedule (if applicable):__________________________________________________

Court Orders on File (if applicable): Yes_____ No____

**EduCare cannot withhold a child from a legal guardian if court orders are not on file**

List Siblings & Their Ages:

______________________________________________________________________________

Language(s) Spoke in Home:______________________________________________________

Individuals Who Can Pick Up Your Child

List persons approved to pick up your child. Your child will only be released to these people. List the contacts in order

that you want us to call them.

As stated in our handbook, these individuals will need to have a photo id (driver’s license) when they pick up your

child for the first time. They may be asked the next time if the teacher in the classroom did not see them the first time.

Please let the contact person know this before picking up your child.

Contact #1

Name: ____________________________________________________________________________________________

Home Address:______________________________________HomePhone:_____________________________________

Work:_____________________________________________ Work Phone: _____________________________________

Contact #2

Name: ____________________________________________________________________________________________

Home Address:______________________________________HomePhone:_____________________________________

Work:______________________________________________ Work Phone: ____________________________________

Contact #3

Name: ____________________________________________________________________________________________

Home Address:______________________________________HomePhone:_____________________________________

Work:_____________________________________________ Work Phone: _____________________________________

**************************************************************************************************

Medical Records

We treat children’s medical information confidentially and share this information only when there is a legitimate need

for it. In order to protect confidentiality and the disclosure of children’s records, documents shall be made available to

program personnel. Disclosure of children’s records beyond guardians, program personnel, and consultants having an

obligation of confidentiality, shall require consent. (Except in the case of abuse or neglect) Please list two individuals

who can have access to your child’s health records besides parents/guardians.

1. (Name)___________________________(Address)_______________________________(Phone)____________

2. (Name)___________________________(Address)_______________________________(Phone)____________

Permission for Child to Participate in EduCare Activities

1. I hereby grant permission for my child to use all play equipment and participate in all

activities. Yes __________ No__________

List Restrictions: _______________________________________________________________

2. I hereby grant permission for my child to participate in supervised walk and outside play

activities involving various college programs: Yes__________ No__________

3. I hereby grant permission for my child to be included in evaluations/developmental checklists

connected with the program: Yes__________ No__________

4. I hereby grant permission for my child to participate in class field trips which may involve

transportation (parents will always be notified prior to field trip to sign additional permission

form): Yes_________ No_________

5. I hereby grant permission for my child to be included in photographs and video tapings for

instructional, publicity, portfolio purposes, and social media sites (names and ages will not be listed on public

web pages): Yes__________ No__________

6. I hereby grant permission for my child’s allergies and picture to be posted in the kitchen and classroom for

proper identification and safety of the child: Yes ___________ No ___________

I hereby attest that I have read the policies of the parent handbook of the Butler Community

College EduCare Center, that I do understand them fully, and that I will adhere to them in good

faith. I will provide necessary health records, immunizations, and an emergency release form for

my child. I will pay all fees when due.

______________________________ _____________________ ____________________

Signature of Parent/Legal Guardian *Social Security # Date

*All parents must prepay for services offered. However, we realize payments may be forgotten or payment

arrangements will be made with the center. Therefore, since EduCare is offering a credit to parents, social

security numbers are needed for collection purposes only. If you choose not to submit your SS # then EduCare

reserves the right to refuse service to your child for any payments missed or late payments.

click to sign

signature

click to edit

Children: (First Grade-12 years)

Grade Placement: _______________ School:______________________

Toys & Activities child enjoys at home:

______________________________________________________________________________

Does your child enjoy playing alone or with others:

______________________________________________________________________________

Hobbies:

______________________________________________________________________________

Other comments and advice:

______________________________________________________________________________

Family Information:

The following requested information is suggested by National Association for the Education of Young

Children. This information will allow the EduCare Center staff to better meet children’s needs and interest.

Some of the information may be private information for your family. Please do not feel obligated to answer

any questions you do not feel comfortable sharing.

What are some of the values you instill in your child?

______________________________________________________________________________

How do you define your religion? __________________________________________________

How do you define your culture? __________________________________________________

What religious and culture celebrations/observations does your family participate in?

______________________________________________________________________________

Would you be willing to share information with the center about these practices?

Yes _____ No_____

Which is more important- for a child to form a strong relationship with one individual teacher or

for a child to have good relationships with several teachers?

______________________________________________________________________________

Which is more important to you: helping children achieve independence or helping them to

develop respect for authority? Why?

______________________________________________________________________________

What are your values and beliefs about expressing emotions? What is important to you about

how children deal with anger? Fear?

______________________________________________________________________________

How do your values affect your response to children’s play? For example, how do you react

when boys pretend to be baby-tenders, or choose to wear “girls” clothes?

______________________________________________________________________________

What is an appropriate response to classroom “misbehavior”?

______________________________________________________________________________

How can you resolve conflicts of value or practice in ways that are supportive of family values?

______________________________________________________________________________

How do program and teacher values match home and family values, and where do differences

exist?

______________________________________________________________________________

CCL. 029 Kansas Department of Health and Environment

Rev. 8/2013 Bureau of Family Health

Child Care Licensing Program

1000 SW Jackson, Suite 200

Topeka, KS 66612-1274

Phone (785) 296-1270 Fax (785) 296-0803

Website: www.kdheks.gov/kidsnet

MEDICAL RECORD FOR ALL CHILDREN IN CHILD CARE FACILITIES,

INCLUDING PROVIDER’S OWN CHILDREN

Parents are to complete the Medical Record and the History of Immunizations for each child in licensed child care

facilities. The Medical Record, History of Immunizations, and Child Health Assessment are transferable when the child

moves to another licensed child care facility.

Child’s First Day in Child Care Name of Child Care Facility

Child’s Name Date of Birth Gender

First Last MM/DD/YYYY M/F

Parent/Guardian Information Parent/Guardian Information

Name Name

Home Address Home Address

Street City Zip Code Street City Zip Code

Home Phone Number Home Phone Number

Work Address Work Address

Street City Zip Code Street City Zip Code

Work Phone Number Work Phone Number

Cell Phone Number Cell Phone Number

E-mail Address E-mail Address

Best way to contact Best way to contact

Names and ages of children in family

Persons authorized to pick up the child or to notify in case of emergency. Include name, address, and telephone number.

Attach an additional page, if necessary.

Child’s Physician Phone Number

Child’s Dentist Phone Number

Hospital Preference (for emergencies)

Has your physician approved the use of any non-prescription medications for your child such as acetaminophen, cough

syrup, or ointments that can be given by the child care provider?

No Yes, as follows:

Does your child have any of the following conditions (yes or no)? If yes, provide information on Authorization for

Emergency Medical Care form CCL. 010.

Allergies Frequent sore throats/colds Ear Aches

Asthma Speech, Visual, Hearing Diabetes

Epilepsy/Seizures Other

If yes answered to any above, please provide additional information

Have there been major changes at home that might affect your child in care? No Yes, as follows:

Please provide additional information or special instructions that will help the person caring for your child.

P

arent/Guardian Signature:_________________________________________

Date:_____________

1

Butler EduCare Center

History of Immunizations

Required for all children in child care facilities, including the provider’s own children. A Kansas Certificate of

Immunizations (KCI) may be substituted for this form and attached to the completed Medical Record.

Child’s Name: Date of Birth:

First Last MM/DD/YYYY

Section I. For a recommended schedule of immunizations, refer to the current schedule published by the

Advisory Committee on Immunization Practices (ACIP).

Vaccine

Record the Month. Day and Year that each Dose of Vaccine was Received

1

st

2

nd

3

rd

4

th

5

th

6

th

Diphtheria, Tetanus, Pertussis

(DTaP)

Poliomyelitis (IPV/OPV)

Measles, Mumps, Rubella

(MMR)

Hepatitis B (HepB)

Varicella (VAR)

Hx of Disease: Date of Illness:

Physician Signature

Hemophilus Influenzae Type B (Hib)

Pneumococcal Conjugate (PCV)

Hepatitis A (HepA)

Rotavirus

**Recommended <8 mo of

age; not required

Influenza(Flu) ** Recommended

annually >6 mo of age; not required

Section II.

Complete this section only if your child is exempted from the law requiring immunizations [K.S.A. 65-508(d)].

Section II. Complete Section below only if your child is exempted from laws requiring requiring

immunizations [ K.S.A. 65-508(d) and K.S.A. 65-519(c) ]

Section III.

2

The following two options are the ONLY exemptions allowed by law. Please check either (A) or (B) below and

complete as required:



(A) Certification from licensed physician stating that immunization would endanger child’s life:

Exempt from following immunizations:

DTaP/DT _____Tdap/TD Pertussis Only ____Polio MMR HepA HepB Hib

_____

PCV ____Varicella ___Other

Physician’s Signature (required): ________________________________________________Date:_______________



(B) My child is exempt under the law from immunizations. As the Parent or Legal Guardian, I state

that I am an adherent of a religious denomination whose teachings are opposed to immunizations.

Parent/Guardian Signature:_________________________________________Date:________________

CCL. 029a

Rev. 8/2013

Child Health Assessment

The Child Health Assessment form is to be completed and signed by a nurse approved by KDHE to perform Child Health

Assessments or a Licensed Physician. If a Physician Assistant (PA) completes the Child Health Assessment, the signature

of the Licensed Physician authorizing the PA is to be included at the bottom of this form.

A Child Health Assessment, recorded on a KDHE Form or other acceptable Forms mentioned below, is required for all

children including children of the provider or staff in Licensed Day Care Homes, Group Day Care Homes, Child Care

Centers and Preschools. A Kan-Be-Healthy Assessment Form is a KDHE Form and is acceptable, a Physician Health

Assessment Form is acceptable, and a School Health Assessment Form is acceptable for school-age children or youth.

The Health Assessment Form used should be attached to the KDHE Medical Record Form (CCL. 029).

Child’s Name_________________________________________ Date of Birth___________________

First Last

Health history and medical information pertinent to routine child care and emergencies

(describe, if any):



None

Do you see this child for regular

health supervision:



Yes



No

Allergies to food or medicine (describe, if any):



None

List current medications (if any):



None

Length/Height:

______IN/CM %ILE_______

Weight: _____LB/KB %ILE_______

Physical Examination  If Normal If Abnormal - Comments

Head/Ears/Eyes/Nose/Throat

Teeth

Cardio/Respiratory

Abdomen/GI

Genitalia/Breasts

Extremities/Joints/Back/Chest

Skin/Lymph Nodes

Neurologic & Developmental

Screening Tests

Screening Date

Note Here if Results are Pending or Abnormal

Lead

Anemia (HGB/HCT)

Urinalysis (UA)

Hearing

Vision

Health Problems or Special Needs, Recommended Treatment/Medications/Special Care (Attach additional sheets if necessary)



None

Signature of Licensed Physician or Nurse approved for Child Health Assessments

Date

Print the Name of the Individual Signing Above

Phone Number

Address City Zip Code

3

CCL 010 Kansas Department of Health and Environment

Rev. 6/2015 Bureau of Family Health

1000 SW Jackson, Suite 200

Topeka, KS 66612-1274

Child Care Program: (785) 296 -1270 Fax: (785) 296 -0803

Website: www.kdheks.gov/kidsnet

AUTHORIZATION FOR EMERGENCY MEDICAL CARE

Written permission for emergency medical treatment must be on file at the facility. Consult with the local emergency medical

facility to be sure this form is acceptable. Reference K.A.R. 28-4-127(b)(1)(A). School Age Programs reference K.A.R. 28-4-

582(e)(2).

Name of facility exactly as stated on the license.

License #

I hereby authorize _________________________________________________________ (Name of individual/staff member) and/or

____________________________________________________ (Name of individual/staff member) who is (are) representative(s) of the

above named facility to give consent for any and all necessary emergency medical care for my child or youth _____________________

___________________________________________ (First and Last Name of Child or Youth) while said child or youth is in said facility’s

custody between the dates of ___________________________ and ____________________________.

MM/DD/YYYY MM/DD/YYYY

Signature of Parent or Guardian

Date Signed

Witness to Parent’s or Guardian’s signature if required by the local hospital or clinic.

Date Signed

Notarization of Parent’s or Guardian’s signature if required by local hospital or clinic.

State of Kansas

County of ________________________

Signed or attested before me on ____________________ by______________________________________________.

MM/DD/YYYY Name of Person

(Seal, if any.)

_______________________________________________

Signature of notarial officer

______________________________________________

Title (and Rank)

My appointment expires: __________________________

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

List any known allergies or other information about the medical status of this child or youth pertinent in case of emergency:

Is child covered by health insurance?  Yes  No

If yes, complete the following:

Health Insurance Policy Name _________________________________________ Policy Number ______________________

Medical Assistance Program ____________________________________________ Card Number________________________

Military Medical Care I.D. Number ___________________________________________________________________________

If known, date of last Tetanus inoculation: __________________________________

THE MEDICAL RECORD/ASSESSMENT FORM (OR HEALTH STATUS HISTORY FORM FOR SCHOOL AGE PROGRAMS) AND THE

AUTHORIZATION FOR EMERGENCY MEDICAL CARE MUST BE TAKEN TO THE EMERGENCY ROOM. BOTH FORMS MUST

ALSO BE IN A VEHICLE WHEN THE CHILD OR YOUTH IS TRANSPORTED BY THE FACILITY.

Butler EduCare Center

0029273-013

Butler EduCare Center

until terminated

CCL. 034 Kansas Department of Health and Environment

Rev. 8/2013 Bureau of Family Health

Child Care Licensing Program

1000 SW Jackson, Suite 200

Topeka, KS 66612-1274

Phone: 785-296-1270 Fax: 785-296-0803

Website: www.kdheks.gov/kidsnet

PARENTAL PERMISSION FORM FOR OFF-PREMISES TRIPS

Name of the Facility (exactly as stated on the license)

License #

Street Address of the Facility

City

Zip Code

County

_______________________________________may go to the following locations off the premises with adult supervision:

First and Last Name of Child or Youth

Place

Street Address

City

By Vehicle

Walk/Bike

Signature of Parent or Guardian

Date Signed

Place

Street Address

City

By Vehicle

Walk/Bike

Signature of Parent or Guardian

Date Signed

Place

Street Address

City

By Vehicle

Walk/Bike

Signature of Parent or Guardian

Date Signed

Place

Street Address

City

By Vehicle

Walk/Bike

Signature of Parent or Guardian

Date Signed

Place

Street Address

City

By Vehicle

Walk/Bike

Signature of Parent or Guardian

Date Signed

Place

Street Address

City

By Vehicle

Walk/Bike

Signature of Parent or Guardian

Date Signed

Place

Street Address

City

By Vehicle

Walk/Bike

Signature of Parent or Guardian

Date Signed

Butler EduCare Center

0029273-013

901 S Haverhill Rd

El Dorado

67042

BU

Campus Walks

901 S Haverhill Rd

El Dorado

X

Place

Street Address

City

By Vehicle

Walk/Bike

Signature of Parent or Guardian

Date Signed

Place

Street Address

City

By Vehicle

Walk/Bike

Signature of Parent or Guardian

Date Signed

Place

Street Address

City

By Vehicle

Walk/Bike

Signature of Parent or Guardian

Date Signed

Place

Street Address

City

By Vehicle

Walk/Bike

Signature of Parent or Guardian

Date Signed

Place

Street Address

City

By Vehicle

Walk/Bike

Signature of Parent or Guardian

Date Signed

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

FOR SCHOOL AGE CHILDREN OR YOUTH ONLY

I hereby authorize my school age child ___________________________________________________________________

First and Last Name of Child or Youth Birth Date MM/DD/YYYY

To walk/bike to and from the following location(s) without adult supervision:

Place

Street Address

City

By Vehicle

Walk/Bike

Signature of Parent or Guardian

Date Signed

Place

Street Address

City

By Vehicle

Walk/Bike

Signature of Parent or Guardian

Date Signed

Place

Street Address

City

By Vehicle

Walk/Bike

Signature of Parent or Guardian

Date Signed

Place

Street Address

City

By Vehicle

Walk/Bike

Signature of Parent or Guardian

Date Signed

Parent Partnership Form

We strive for strong family relationships. Research shows parent involvement increases child success.

Please sign up for areas in which you would be interested in helping.

Child’s Name:____________________________ Classroom:_______________________

 Attending fieldtrips

 Assisting in special classroom activities

 Assisting in community events

 Assisting in monthly parent activities

 Serve on EduCare Parent Board

 Write advocacy letters

 Assist in Teacher Appreciation Activities

 Read to the children in the classroom

 Any other special gifts and talents you would like to share please list

below:

________________________________________________________

Center E/IEF

Dear Parent or Guardian:

Our center has been approved for participation in the Child and Adult Care Food Program (CACFP). The CACFP reimburses the center for the partial

cost of meals. Participation in the CACFP enables us to keep our fees lower as well as serve nutritious meals to children in our program.

The parent/guardian must complete Parts 1 and 4 and one of the following options: Part 2, Part 3A or Part 3B, to determine the amount of CACFP

funds the center will be eligible to receive. This form will be placed in our files and treated as confidential information. Note: no white out or erasure

should be used. If there is an error cross through, correct, and initial.

Part 1 FOR CHILD ENROLLMENT:

 CHILD’S NAME: List the first and last name of all children enrolled at this center.

 DATE OF BIRTH: List each child’s date of birth.

 TIMES OF CARE, DAYS OF CARE and MEALS SERVED: List the regular times of care for each child by listing their arrival time and leave time,

check each day the child will be in care and check each meal type received while in care.

 ETHNICITY/RACE: Using the codes provided, enter the codes for ethnicity and race.

 FOSTER CHILD: If the child is a foster child (the legal responsibility of a foster care agency or the court), please check the box.

Part 2 FOR A HOUSEHOLD RECEIVING BENEFITS FROM THE FOOD ASSISTANCE PROGRAM (FAP), TEMPORARY ASSISTANCE FOR

FAMILIES (TAF), OR FOOD DISTRIBUTION PROGRAM ON INDIAN RESERVATIONS (FDPIR):

 Complete Parts 1, 2 and 4 on the reverse side.

 Provide the name and case number for the program from which benefits are received.

Part 3A FOR A HOUSEHOLD EXCEEDING THE INCOME GUIDELINES LISTED ON THE CHART BELOW:

 Complete Parts 1, 3A and 4 on the reverse side.

TO CALCULATE ANNUAL INCOME

Weekly Income X 52  Every 2 Weeks Income X 26  Twice a Month Income X 24  Monthly Income X 12

Part 3B FOR ALL OTHER HOUSEHOLDS:

 Complete Parts 1, 3B and 4 on the reverse side using the additional information below.

 HOUSEHOLD NAMES: Write the names of everyone in your household not listed in Part 1. Include yourself and all other children, your spouse,

grandparents, other relatives and unrelated people in your household. Use a separate sheet of paper if you do not have enough space.

 GROSS INCOME BEFORE DEDUCTIONS: Write the amount of income each person gets on the same line as their name. Use the appropriate

column(s): Earnings from Work, Welfare/Child Support/Alimony, Pensions/Retirement/Social Security or Other Income (see list below). Next to the

amount of income write how often the income was received. Income is all money before taxes or anything else is taken out. If a person does not

have income, check the box for zero income.

OTHER INCOME: strike benefits, unemployment compensation, worker’s compensation, disability benefits, interest/dividends, cash

withdrawn from savings, income from estates/trust/investments, royalties/annuities/rental income, and regular contributions from persons not

living in the household.

FOSTER CHILDREN: List any personal income received by the foster child under Part 3B. Personal income is (a) money given for the child’s

personal use, such as clothing, school fees and allowances and (b) all other money the child gets, such as money from his/her family.

MILITARY HOUSING BENEFITS: Report off-base housing allowance as income. If the housing is part of the Military Housing Privatization

Initiative, do not include as income.

SELF-EMPLOYMENT: Report income derived from the business venture less operating costs for net income. The loss from the business

cannot be deducted from a positive income earned in other employment. The least possible income is zero.

 SOCIAL SECURITY NUMBER: Write the last four (4) digits of the social security number of the adult household member who signs the form. If the

adult household member does not have a social security number, check the box. Use of this information is for CACFP use only and is required.

Part 4 SIGNATURE AND CONTACT INFORMATION:

 Sign and date the application. The form must be signed by the parent or guardian.

 Complete the contact information – name, address, telephone number, and employer information.

In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices,

and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin,

sex, disability, age, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA.

Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign

Language, etc.), should contact the Agency (State or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech

disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages

other than English.

To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) found online at:

http://www.ascr.usda.gov/complaint_filing_cust.html, and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the

information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by:

(1) Mail: U.S. Department of Agriculture

Office of the Assistant Secretary for Civil Rights

1400 Independence Avenue, SW

Washington, D.C. 20250-9410;

(2) Fax: (202) 690-7442; or

(3) Email: program.intake@usda.gov.

This institution is an equal opportunity provider.

Household Size:

1

2

3

4

5

6

7

Each Add’l Family Member

Annual Income:

$22,459

$30,451

$38,443

$46,435

$54,427

$62,419

$70,411

+ $7,992

click to sign

signature

click to edit

ENROLLMENT & INCOME ELIGIBILITY FORM FOR CHILD CARE CENTERS

JULY 1, 2018 THROUGH JUNE 30, 2019

Part 1. CHILD ENROLLMENT: Complete the information below for all children in care. If the child is a foster child (legal responsibility

of a foster care agency or the court), please check the box.

Last Name, First Name

Date of

Birth

Times of Care

Regular Days of Care

Meals Served

During Care

Ethnicity/

Race*

Foster

Child

Arrival

Time

Leave

Time

M

T

W

T

F

S

B

A

M

L

P

M

D

E

V

Ethnicity

Race



*Ethnicity (select one): H=Hispanic or Latino or N=Not Hispanic or Latino

*Race (select one or more): W=White, B=Black or African American, I=American Indian or Alaskan Native, A=Asian, or P=Native Hawaiian or other Pacific Islander

Part 2. HOUSEHOLDS RECEIVING BENEFITS FROM THE FOOD ASSISTANCE PROGRAM (FAP), TEMPORARY ASSISTANCE FOR FAMILIES

(TAF), OR FOOD DISTRIBUTION PROGRAM ON INDIAN RESERVATIONS (FDPIR): Complete Parts 1, 2 and 4.

Program Name: ___________________________________________________________ Case No. _____________________________

Part 3A. HOUSEHOLDS EXCEEDING THE INCOME GUIDELINES: Complete Parts 1, 3A and 4.

If your family income exceeds the income guidelines (listed on reverse side), check this box 

Part 3B. ALL OTHER HOUSEHOLDS – If you do not have a FAP, TAF or FDPIR case number: Complete Parts 1, 3B and 4.

GROSS INCOME BEFORE ANY DEDUCTIONS (Net for Self Employed)

W=Weekly E2=Every 2 weeks 2M=Twice monthly M=Monthly Y=Yearly

List the Names of All Household

Members not listed in Part 1

Earnings from Work

Welfare, Child Support,

Alimony

Pensions, Retirement,

Social Security

All Other Income

Check

If

ZERO

income

How much?

How often?

How much?

How often?

How much?

How often?

How much?

How often?

(Example) Jane Smith

$200

W

$150

2M

$100

M

1



2



3



4



5

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6



Social Security Number of Household Member who signs form:

Last four digits of Social Security Number:

XXX

-

XX

-____________ If you do not have a Social Security Number, check this box 

Privacy Act Statement: The Richard B. Russell National School Lunch Act requires the information on this application. You do not have to give the information, but if you do not, we cannot approve your child for free or

reduced price meals. You must include the last four digits of the social security number of the adult household member who signs the application. The social security number is not required when you apply on behalf of

a foster child or you list a Food Assistance Program (FAP), Temporary Assistants for Families (TAF) or Food Distribution Program on Indian Reservation (FDPIR) case number for your child or other (FDPIR) identifier or

when you indicate that the adult household member signing the application does not have a social security number. We will use your information to determine if your child is eligible for free or reduced price meals, and

for administration and enforcement of the CACFP.

Part 4. SIGNATURE AND CONTACT INFORMATION:

I certify that all information on this form is true and that all

income is reported. I understand that the facility will receive

Federal funds based on the information I give. I understand that

CACFP officials may verify the information. I understand that if I

purposely give false information, the participant receiving meals

may lose their meal benefits, and I may be prosecuted.

_____________________________________

Signature of Parent or Guardian Date

________________________________________________

Print Name

________________________________________________

Address

________________________________________________

City State Zip Code

________________________________________________

Daytime Telephone

________________________________________________

Employer(s)

FOR CENTER USE ONLY

_____ FAP/TAF/FDPIR HOUSEHOLD

_____ Homeless Documentation from school, emergency shelter, or agency

_____ ANNUAL INCOME: _________________ HOUSEHOLD SIZE: _________

__________________________________________________________________

Sponsor’s Determining Signature Date

__________________________________________________________________

Sponsor’s Confirming Signature Date

HOUSEHOLD CATEGORY:  Free

 Reduced Price

  Paid

Foster Child – Free Category

List name of foster child(ren):

Please indicate, by initialing, your choice of products that you would like used for your

child. By initialing you are giving permission for EduCare staff to use the following. All

authorized products must be furnished by the parent.

*Any items below that are “medicated” will require a long term medication form*

__________ Toothpaste used daily to brush teeth after lunch.

Circle your choice: Fluoride Non Fluoride

__________ Sunscreen applied for outdoor play from Apr. 1 to Nov. 1

(Sunscreen or sun block must have UVB and UVA protection of SPF

15 or higher and must be a non-aerosol bottle. Sunscreen may not

be combined together with bug repellant.)

__________ Hand or body lotion applied as needed throughout the year

__________ Diaper Cream applied as needed throughout the year

_________ Bug repellant applied for outdoor play 1x per day only

(Bug repellant not allowed for children under 2 months of age.

Parents must complete a long term medication form. Repellant

must be in a non-aerosol container and cannot be combined with

sunscreen.)

__________ Equate Triple Antibiotic Ointment (used for cuts and scrapes)

furnished by the center. (Parent’s must complete a long term

medication form.)

Child’s Name: ______________________________________________________________________

Parent’s Signature: ____________________________________________ Date: _____________

Butler Community College EduCare Center Learning Lab

901 S. Haverhill

El Dorado, Kansas 67042

316-323-6845

FEE AGREEMENT

Butler Community College EduCare Center Leaning Lab and _____________________________ mutually, freely, voluntarily enter

into the following contract:

We agree to provide childcare service for________________________, from the date of this contract until otherwise terminated

as provided for below. The hours of service fill depend upon sufficient demand but are approximately 5:45 a.m. to 6:00

p.m. Monday through Friday.

In this consideration for the above rendered, I agree to pay $________________ per day for child care services. Contracted

days will be _____________________________. An enrollment fee of $50.00 per family is required at the time of enrollment. The

enrollment fee is non-refundable and will reserve a place in the class until designated start date. There is a $15.00

supply fee charged per semester during the fall and spring semesters and an activity fee during the school age summer

program for field trips.

I agree to abide by the following policies:

1) The policy of Butler EduCare regarding parental joint custody, parents with custody or visitation rights and other

custodians if children are as follows: We will only release children to authorized custodians as listed on the

enrollment form. If the undersigned wishes that someone other than their names to be authorized to obtain their

child from the center, they must inform the center prior to the release. Custodial parents must give written

permission for non-custodial parents to pick up the child. A legal document must be provided if a parent is

prohibited from picking up their child.

2) All accounts are to reflect a zero balance by the 15

th

of each month. Late fees will be assessed on the 16

th

of every

month. If payments are past due, a $10.00 late fee will be assessed weekly. If you receive four late fees in a

program year, your child will be subject to dismissal. It is your responsibility to keep your account at a zero

balance. If payment is not received by the first day of the month after the billing month, the child(ren) will not be

allowed to attend until payment has been made. If this occurs three months in a rown, child(ren) is/are subject

to removal from EduCare.

3) Families who are eligible for funding from the Department of Children and Families (DCF) will process all

payments through an EBT card issued to the client. Our EBT provider number is B796479.

4) Parent(s) will be responsible for payment of days when their child/ren are ill are absent. Parent(s) are not

charged for scheduled closing days. Parents will still be responsible for unforeseen closing due to extreme

weather etc.

5) All schedule changes must be submitted in writing to the Director or Assistant Director at least 14 days prior to

the date of change. Approved schedule changes made after the start of the billing cycle will take effect on your

next regularly scheduled billing statement.

6) If childcare services are to be terminated, parent(s) must give two weeks or ten school days written notice to the

office. Free vacation days/coupons may not be used at this time. If the child’s behavior is physically or

emotionally dangerous to the other children or staff, immediate termination may be necessary. Child Care

services may also be terminated immediately if the behavior of a parent or primary caregiver is verbally

disrespectful or physically abusive to a staff or other children or parents in the program. A child’s enrollment will

never be terminated without first informing the parents of the problem and working together with a parent to

resolve the problem. The enrollment fee is non-refundable.

7) Polices are set forth in the parent handbook presented to each parent(s) at the time the child(ren) is enrolled.

8) All policies are subject to change upon approval of Butler Board of Trustees;

IN WITNESS WEREOF, THE PARTIES HAVE EXECUTED THIS AGREEMENT AT EL DORADO, KANSAS; ON

___________________ By___________________________________ _______________________________________________

Date Butler Administration Parent or Guardian

We are excited to offer the safety, convenience and ease of Tuition Express

®

— a payment processing system that allows secure,

on-time tuition and fee payments to be made from either your bank account or credit card.

ELECTRONIC FUNDS TRANSFER AUTHORIZATION FOR BANK ACCOUNT and CREDIT CARD

I (we) hereby authorize (business name) ________________________________________ to initiate credit card charges to

the below-referenced credit card account (Section A) OR, initiate debit entries to my (our) checking or savings account,

indicated below (Section B). To properly affect the cancellation of this agreement, I (we) are required to give 10 days written

notice. _____ (initial) Credit union members: please contact your credit union to verify account and routing numbers for automatic

payments. Check with the center for accepted credit card types.

COMPLETE ONE SECTION ONLY

SECTION A (Credit Card)

_______________________________________________________________________________________________________

Cardholder Name Phone #

_______________________________________________________________________________________________________

Cardholder Address City State Zip

_______________________________________________________________________________________________________

Account Number Expiration Date

_________________________________________________________________________________________________________________________________

Cardholder Signature Date

SECTION B (Bank Account)

_______________________________________________________________________________________________________

Your Name Phone #

_______________________________________________________________________________________________________

Address City State Zip

_______________________________________________________________________________________________________

Bank or Credit Union Name Bank or Credit Union Address City State Zip

_______________________________________________________________________________________________________

Routing Transit Number (see sample below) Account Number (see sample below)

_______________________________________________________________________________________________________

Authorized Signature Date

Automated Payment Processing

Safe – Convenient – Easy

For Ofcial Use Only

Date Received

________________________

Employee Signature

________________________

A service of

Checking Savings

Copyright Procare Software 3/15/16

USDA is an equal opportunity provider and employer.

United States Department of Agriculture

Food and Nutrition Service

FNS-317

June 2000

Revised June 2001

Building for the Future

This child care receives

Federal cash assistance to

serve healthy meals to your children.

Good nutrition today means

a stronger tomorrow!

Meals served here must meet

nutrition requirements established by USDA’s

Child and Adult Care Food Program.

Questions? Concerns?

Call USDA toll free: 1-866-USDA CND

(1-866-873-2263)

Visit USDA’s website: www.fns.usda.gov/cnd

Construyendo Para El Futuro

Esta guardería infantil recibe

asistencia monetaria del gobierno federal

para servir comidas nutritivas a sus niños.

¡Buena nutrición hoy significa

un mañana más saludable!

Comidas servidas aquí deben de seguir los

requisitos nutricionales establecidos por el programa

"Child and Adult Care Food Program"

del Departamento de Agricultura de los Estados Unidos

(USDA por sus siglas en inglés).

¿Preguntas? ¿Inquietudes?

Llame gratuitamente a USDA al:

1-866-USDA CND

(1-866-873-2263)

Visite el website de USDA: www.fns.usda.gov/cnd

USDA es un proveedor y empleador que ofrece oportunidad igual a todos.

United States Department of Agriculture

Food and Nutrition Service

FNS-317-S

June 2000

Revised June 2001

Fill Online, Printable, Fillable, Blank Butler Educare Center Learning Lab Enrollment Packet School Age (Butler Community College) Form

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Fillable Butler Educare Center Learning Lab Enrollment Packet School Age (Butler Community College)

Fill Online, Printable, Fillable, Blank Butler Educare Center Learning Lab Enrollment Packet School Age (Butler Community College) Form

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