Fillable Fairfield Christian Academy Childcare Enrollment Checklist (Fairfield Christian Academy)

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Fairfield Christian Academy Childcare Enrollment Checklist (Fairfield Christian Academy)

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Child’s Name
FAIRFIELD
CHRISTIAN
ACADEMY
Fairfield Christian Academy Childcare Enrollment Checklist
Thank you for your interest in Fairfield Christian Academy’s childcare services.
To complete the enrollment process, please finish each item on the checklist below.
$65 Application Fee (check made payable to FCA)
Complete and Sign Family and Additional Information (Family Information Pages)
Complete Emergency Medical Release (Form A)
Complete Transporation Premission Sheet (Form B)
Complete FACTS Agreement (Form C)
Sign Liability Release/Acknowledgement of Policies (Form D)
Child Medical Statement (Must be signed by your child’s physician)
Acquire a copy of immunization records from your child’s physician
Enroll in FACTS online at www.online.factsmgt.com/signin/3CP5
for tuition payment plan
Child’s Name
FAIRFIELD
CHRISTIAN
ACADEMY
Family Information
First Contact Spouse
Street Address
City
State
Zip
Home Phone
Cell Phone
Work Phone
Email
Best number you can be reached at during this program?
Work
Job Title
Employer
Home
Cell
Student resides with: Father/Mother (same residence)
Mother (separate residence)
Father (separate residence)
Other:
Name (please print)
Relationship to Student
Is either parent (or other) forbidden by court order from having equal access to the child or school records?
No
Yes
Copies of custody paperwork must be submitted with this application.
Has your child ever attended child care or preschool at FCA?
Additional Information
Does your child have any siblings that are currently enrolled in FCA Childcare/Preschool or FCA K-12?
Has your child ever been diagnosed with a speech or hearing disability?
No
Yes
Please explain your child’s previous schooling or child care experiences.
No
Yes
If yes, please provide their names:
No
Yes
Is your child potty trained? (All students are required to be fully potty trained to attend preschool)
No
Yes
Second Contact Spouse
Street Address
City
State
Zip
Home Phone
Cell Phone
Work Phone
Email
Best number you can be reached at during this program?
Work
Job Title
Employer
Home
Cell
Child’s Name
FAIRFIELD
CHRISTIAN
ACADEMY
List any chronic physical problems and history of hospitalization:
Does your child wear glasses?
No
Yes
No
Yes
If yes, where?
List any diseases that your child has had:
Do you attend church?
No
Yes
Has your child ever been dismissed or asked to leave a school or child care facility?
If yes, please explain
Has your child ever been tested for behavioral, emotional or psychological conditions or any other conditions
that require specialized care?
No
Yes
If yes, please explain
Do you feel there are any characteristics relating to the health or personality of your child that may be
helpful to your child’s teacher?
No
Yes
If yes, please explain
Please select the appropriate race/ethnic class for your child (The IRS and Ohio Reporting requirement
request this information).
African American
I do not wish to provide this information
Native American
Hispanic
White
Multi-racial
Asian
Race/Ethnicity
Parent/Guardian Signature
Date
FORM A
Emergency Medical Authorization
CHILD’S NAME__________________________
PLEASE PRINT and use BLACK or BLUE Ink ONLY:
Gender
Date of Birth
Grade
Primary Number
Street Address
City
State
Zip
Section 3313.712 of the Ohio Revised Code requires the following: Purpose – To ENABLE parents and guardians to authorize the provision of
emergency treatment for children who become ill or injured while under school authority when the parents or guardians cannot be reached.
Part 1 or Part 2 MUST BE COMPLETED.
Part 1 (To Grant Consent)
In the event reasonable attempts to contact me or the other parent/guardian listed below at the numbers provided have been unsuccessful, I
HEREBY GIVE MY CONSENT for (1) the administration of any treatment deemed necessary by the preferred physician or preferred dentist listed
below, or in the event the designated preferred practitioner is not available, by another licensed physician or dentist; and, (2) the transfer of the child:
outside of Fairfield County to the nearest emergency facility, or in Fairfield County, to Fairfield Medical Center. If the situation necessitates transport
to another facility, those arrangements would be made through Fairfield Medical Center or the facility outside of Fairfield County to which the child
has been transported. This authorization does not cover major surgery unless the medical opinions of two other licensed physicians or dentists,
concurring in the necessity for such surgery, are obtained prior to the performance of such surgery. Please complete answers below to which the
physician should be alerted:
ALLERGIES
Y/N
Please explain “yes” answers
Environmental
Food
Insects (bees)
Medication
IS HE/SHE ON MEDICATION (prescription and over-the-counter medication the child takes on a regular basis)?
Medications (Name and Strength)
Dose/Frequency
Days Taken
Home
School
MEDICALCONDITIONS: _________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
1st Contact
Parent/Guardian
2nd Contact
(If no 2
nd
Parent/Guardian,
List Alternative Contact)
Preferred Physician
Preferred Dentist
Name
Relationship
Home Phone
Cell Phone
Work Phone
_____________________________________________________________________ ____________________
Parent/Guardian Signature Date
Part 2 ( Refusal To Consent)
DO NOT COMPLETE Part 2 IF YOU HAVE COMPLETED Part 1
I do NOT give my consent for emergency medical treatment of my child. In the event of illness or injury requiring emergency treatment, I wish the
school authorities to TAKE NO ACTION OR TO:
_____________________________________________________________________ ____________________
Parent/Guardian Signature Date
Child’s Name
FAIRFIELD
CHRISTIAN
ACADEMY
I give ONLY the following people permission to pick up my child from childcare. Please list all possible
persons at this time. Please be sure to include yourself, spouse and those whom you have listed as
emergency contacts. The office must receive additional requests in writing prior to the day that a new
person will be picking up your child.
Parent/Guardian Signature
Date
Transportation Permission
Name Phone Number Relationship to Child
I give permission for my child to be included in videotaping and photos to be used by Fairfield
Christian Academy.
I
do not
give permission for my child to be included in videotaping and photos to be used by Fairfield
Christian Academy.
PHOTO RELEASE
PERMISSION TO PARTICIPATE IN WATER PLAY
I give permission for my child to participate in water play at Fairfield Christian Academy. Water depth
will not exceed two feet.
ANNUAL CLASS ROSTER
I
do not
give permission for my child to participate in water play at Fairfield Christian Academy.
I authorize my child’s name, my name and my phone number to be listed on the parent roster.
I
do not
authorize my child’s name, my name and my phone number to be listed on the parent roster.
FORM B
Drop off Time
Pick up Time
Monday
Tuesday
Friday
Thursday
Wednesday
Child’s Name
FAIRFIELD
CHRISTIAN
ACADEMY
In signing the Statement of Agreement, I/We agree to the following:
1. Tuition and Fees Financial Policy: Tuition and fees will be charged according to the Schedule of Tuition and
Fees adopted by the school for the applicable school year. By signing this contract, I agree to abide by the policies
relating to the payment of such tuition and fees.
2. e person(s) responsible for payment of tuition and fees:
Name: ______________________________________________________ Phone: ________________________
Email address: ______________________________________________________________________________
Billing Address: _____________________________________________________________________________
3. For the next year I will pay my child’s tuition through FACTS:
Monthly Payments: TWELVE monthly payments through FACTS only. (NO cash or check payment
option.) Parents who use the automated process of tuition payments may elect to pay tuition on the 5th
or 20th of each month through the FACTS payment plan. e FACTS annual enrollment fee is $45.
I/we understand that for any student withdrawals, a two week notice is required with two week tuition payments.
Any subsequent changes in my payment option will result in a $20 administrative charge. I/we further
understand that checks returned from the bank for insucient funds, will necessitate a $25 returned check fee
along with paying with cash through the oce. I/We realize that failure to meet this nancial agreement will
result in student withdrawal.
For any additional nancial questions, please send emails to pmccarty@fcaknights.us.
In signing this Statement of Agreement, I/we agree that I am/we are responsible for payment of all tuition and
fees for the child covered by this agreement.
Parent/Guardian Signature
Date
Parent/Guardian Printed Name
Parent/Guardian Signature
Date
Parent/Guardian Printed Name
Childcare FACTS Agreement
FORM C
Child’s Name
FAIRFIELD
CHRISTIAN
ACADEMY
BOTH PARENTS/GUARDIANS MUST SIGN UNLESS ONLY ONE HAS ALL CUSTODY RIGHTS
is Release of Liability is executed in consideration for allowing the above-named child to enroll in Faireld Christian
Academy and to participate in activities related to the school. is Release of Liability must be signed by BOTH parents/
guardians unless only one parent/guardian has all custody rights.
We/I, on behalf of our/my child do hereby release and forever discharge and agree to hold harmless Faireld Christian
Academy, Faireld Christian Church, and the School Administration, Sta and Volunteers, from any and all loss, liability,
claims, or demands of any nature, including but not limited to negligence, which may be incurred by the undersigned, and
the child while he/she is enrolled at Faireld Christian Academy.
Furthermore, we/I and on behalf of our/my child assume all risks of personal injury, sickness, death, damage, and expenses
as a result or participation in recreation, study, and school-related activities in which the designated child is involved.
We/I, the undersigned, further hereby agree to hold harmless and indemnify Faireld Christian Academy,
Faireld Christian Church, and its School Administration, Sta and Volunteers, for any liability sustained by Faireld
Christian Academy, Faireld Christian Church as a result of the negligent, willful, or intentional acts
of the named child, including any related expenses.
Liability Release
I reviewed a copy of the Faireld Christian Academy Childcare Preschool Parent Handbook on Faireld Christian
Academy’s website and I was provided clear and accurate information regarding all policies and guidelines of Faireld
Christian Academy Preschool. I understand the policies and guideline by which the center operates.
I agree to abide by all policies stated in the parent handbook. I understand that I will be notied of any changes made to
these policies.
I also understand that any breach of the center’s policies may be grounds for withdrawal from the program. A two week
notice will be provided in such a circumstance unless the infraction is severe enough to warrent withdrawal without
notice.
I further understand that failure to be prompt and accurate with payment will be grounds for withdrawal.
Acknowledgment of Policies
Parent/Guardian Signature
Date
Parent/Guardian Signature
Date
Parent/Guardian Signature
Date
FORM D
Child’s Name
FAIRFIELD
CHRISTIAN
ACADEMY
Child Medical Statement
is is to certify that I have examined this child and their health records and found that:
1. is child has had the immunizations required by section 3313.671 of the Revised Code for admission to school, or has
had the immunizations recommended by the state department of health according to the child’s age, or is to be exempted
from these requirements for medical reasons. Please note exemptions: ________________________________________.
Immunizations* (enter month, day, and year)
is form, including your child's current immunization record, must be completed and signed by your child's physician and returned to:
Faireld Christian Academy, Attention: Childcare Preschool Department
1965 North Columbus Street, Lancaster, Ohio 43130
Fax Number (740) 654-7689 Telephone (740) 654-2889
Child’s Name (print or type)
Date of Birth
VACCINE DOSE 1 DOSE 2 DOSE 3 DOSE 4 DOSE 5
Diphtheria, Tetanus, Pertussis (DTaP)
Hepatitis B (Hep B)
Haemophilus Inuenza type b (HIB)
Measles, Mumps, Rubella (MMR)
Inactivated Polio
Varicella (chicken pox)
Inuenza
Pneumococcal Conjugate (PCV)
*e immunizations above are recommended immunizations. Please consult your child’s physician for more information.
2. Based upon medical history and physical condition at the time of this examination, this child is in suitable
condition for participation in group care.
3. List any limitations or health conditions (including allergies, daily medications, dietary restrictions)
__________________________________________________________________________________________
Recommended Assessments/Screenings:
Vision: Yes No Date: __________ Hearing: Yes No Date: __________
Dental: Yes No Date: __________ Lead: Yes No Date: __________
BMI: Yes No Date: __________ Other:
Ohio Administrative Code rules 5101:2-12-37 and 5101-2-13-37 require that this examination be given no more
Signature of examining MD/CNP/PA
Date of examination
Name of examining MD/CNP/PA
Street Address
City, State, Zip
Phone
Fax
Ohio Department of Job and Family Services
Child Care Centers and Type A Homes
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Fairfield Christian Academy Childcare Enrollment Checklist (Fairfield Christian Academy)

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Completed 27 February 2021

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