Fill - Free fillable YAM 2019-2020 Enrollment Packet For Tribal Members Final (Chitimacha Tribe of Louisiana) PDF form

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ITEMS REQUIRED TO ENROLL/RE-ENROLL YOUR CHILD

 ___ $50 registration fee

 ___ Completed Enrollment Packet

 ___ Proof of degree of Indian blood (First-Time Students Only)

 ___ Copy of child’s birth certificate (First-Time Students Only)

 ___ Copy of Social Security card (First-Time Students Only)

 ___ Immunization Record

 ___ Proof of monthly income in the form of check stubs, child

support payments, government payments, etc.

 ___ All supplies listed for your child’s room

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Admission Date________________________

Withdrawal Date_______________________

Yaamahana/Chitimacha Child Development Center

General Information Master Form

1. Child’s Name (First)_________________(MI)__________(Last)__________________________

Birth Date ________________________________________________________Sex___________

Mother

Father

Name

Address- P.O. Box

Address- Street

Employer

Home Phone #

Work Phone #

Cell Phone #

Email Address

2. Person with whom the child lives ___________________________________________________

3. Days child will attend center:

_____2 Days (circle the 2 days the child will attend each week - M T W T F )

_____3 Days (circle the 3 days the child will attend each week – M T W T F )

_____5 Days _____ Half Day (Morning only 7:00-12:00)

_____Full Day _____After School Care (Afternoon only 2:30-5:30)

4. Tuition assistance will be based on family income. Please provide proof of monthly household income if you

are interested in assistance. Both parents’ income is required. If not residing together, child support

payments, formal or informal agreements are required. Only parents of tribal children may apply.

Family Size:

_________Number of adults living in the home _________Number of children living in the home

5. Select the best way for your child’s provider to communicate information to you about your child:

___ Written notices ___Email ___Telephone

Yaamahana will not bear responsibility for anything that may happen as a result of false or misleading

information given at the time of enrollment. Parents are responsible for updating all enrollment information.

Parent/Guardian Signature _______________________________________Date:____________________

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Yaamahana/Chitimacha Child Development Center

Emergency Contact & Release Information Form

Child’s Name: ________________________________________________

Mother

Father

Name

Home Phone #

Work Phone #

Cell Phone #

Child’s Doctor:_____________________________________ Doctor’s Phone #:___________________

Child’s Dentist:_____________________________________ Dentist’s Phone #:__________________

Individuals to contact in case of an emergency:

____________________________________________ Phone #:______________________________

Does your child have any food allergies? Yes No

Does your child have any other allergies? Yes No

Does your child have any dietary restrictions? Yes No

Please explain any “yes” answer here:______________________________________________________

______________________________________________________________

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

My child has permission to be released to the following individuals in addition to emergency contact persons

listed above. (Please notify these individuals that they may be asked to show proof of identity.

NAME

RELATIONSHIP

PHONE

I authorize the facility to secure emergency medical treatment for my child.

Parent/Guardian Signature _________________________________Date:__________________________

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Yaamahana

Chitimacha Child Development Center

Payment and Attendance Schedule Agreement Form

____________________________________

Child’s Name

I understand that TUITION PAYMENTS ARE DUE IN ADVANCE OF SERVICES. For example: The child

is enrolled for 3 days a week (T, W, TH) and the parent selected a 2 weeks tuition payment schedule. If the

child starts on a Wednesday, tuition is due on that day for that week (W & TH) and by the close of business on

Tuesday for every two weeks thereafter.

I understand that cash will be accepted at the center. Please make all tuition payments including cash

payments at Yaamahana. Please write checks, cashier’s checks, or money orders to Chitimacha Tribe of

Louisiana. When making a payment in cash, exact change is requested. A $25.00 fee will be assessed to all

NSF checks. If two NSF checks are processed within a year checks will no longer be accepted.

I understand that once tuition payments are 5 business days (1 week) past due, a $5.00 late fee per family will

be assessed. The late fee will continue to be assessed weekly to all accounts with a past due balance.

I understand that once tuition payments are 5 business days (1 week) past due, the Director will send a letter

stating that a payment must be made by the 10

th

day or my child will no longer be able to attend Yaamahana. I

understand that if I choose to re-enroll my child, all tuition fees, late fees and a new registration fee shall be

required before the child is accepted. Once I withdraw my child, I have 30 days to pay the balance before my

account is turned over to the Finance Department.

I select the following tuition payment schedule. Tuition payments will not be refunded.

Please check one:

_____ 1 Week _____ 2 Weeks _____ 4 Weeks

Days child will attend center:

_____2 Days (circle the 2 days the child will attend each week – M T W T F)

_____3 Days (circle the 3 days the child will attend each week – M T W T F)

_____5 Days (circle the 3 days the child will attend each week – M T W T F)

_____ Half Day (Morning Only 7:00-12:00)

_____Full Day _____After School Care (Afternoon only 2:30-5:30)

Parent/Guardian Signature:_______________________________________Date:____________________

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Yaamahana

Chitimacha Child Development Center

Photographing, Videotaping, Audiotaping, and Observation

Release Form

I understand that Yaamahana has video cameras and video equipment that records the daily activities

throughout the facility. These video recordings are conducted for the protection of the children and

staff.

I understand that at various times throughout the year, the staff of Yaamahana will be taking digital

images, photographs, videotapes, and/or audiotapes of the children for educational purposes (e.g.

presentations to train Yaamahana staff), and decoration purposes (e.g. posting pictures on bulletin

boards, in cubbies, etc.).

I understand that parents are also allowed to come into the center and observe, photograph,

videotape, and/or audiotape children.

I, the undersigned, do hereby grant or deny permission to Yaamahana to use the image of my child,

__________________________, as marked by my selection(s) below. Such use includes the

display, distribution, publication, transmission, or otherwise use of photographs, images, and/or

video taken of my child along with his/her first and last name for use in materials that include, but

may not be limited to, printed materials such as brochures and newsletters, videos, and digital images

such as those on the Chitimacha Tribal Web site and the Franklin Banner Tribune.

No child will be observed, video-taped, recorded, or photographed without the supervision of a child

care provider and the authorization of Yaamahana’s Director or Director Designee.

___ Deny permission to use my child’s image at all

___ Grant permission to use my child’s image in the following ways:

___ Limited usage: I want my child’s image and first and last name used on

printed materials only (no digital or video use).

___ Unrestricted usage: I give unrestricted permission for my child’s image and

to be used in print, video, and digital media. I agree that these images may be

used by Chitimacha Tribe of Louisiana for a variety of purposes and that these

images may be used without further notifying me. I do understand that the

child’s last name will not be used in conjunction with any video or digital

images.

Parent/Guardian Signature:___________________________Date:___________________

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Yaamahana/Chitimacha Child Development Center

Non-Vehicular Excursion Authorization

My child, _____________________________, has my permission to participate in

walks, stroller rides, and wagon rides on the reservation. Non-vehicular excursions shall

include nature walks/rides, walks/rides to the Chitimacha Sports Complex, Chitimacha

Tribal School , Rivercane, Chitimacha Recreation Department, Chitimacha Fire Station,

and the Chitimacha Police Station. The children will be accompanied by at least two

Yaamahana staff whenever participating in a non-vehicular excursion. At least one

Yaamahana employee accompanying the children must be currently trained in CPR/First

Aid.

Parent/Guardian Signature:__________________________Date___________________

Parent/Guardian Signature:_________________________ Date___________________

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Yaamahana/Chitimacha Child Development Center

Application of Topical Products Authorization Form

Like all medications, topical ointments must be prescribed or recommended by a licensed

health care provider (Physician – Nurse Practitioner). When trying a new topical product, the

first application should be applied at home and the parent should observe the child for any

adverse reactions.

I give permission for the Yaamahana staff to apply the following topical products to my child

with a one-time authorization.

Child’s Name: ____________________________________________________________

Yes No

( ) ( ) Sunscreen

( ) ( ) Insect Repellant (lotion or alcohol-based repellants are recommended)

( ) ( ) Diaper Rash Ointment

This one time authorization will remain in effect until a new authorization is signed.

Parent/Guardian Signature:________________________________Date:______________

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Yaamahana/Chitimacha Child Development Center

Water Activities Release Form

I understand that children two years of age and above can participate in water play activities in which

there is no standing water, and includes but is not limited to the use of fountains, sprinklers, and

water tables. Children under three years of age, shall not engage in water activities in wading or

swimming pools due to the risk of fecal-oral contamination and disease.

I understand that children three years of age and above, completely toilet-trained, can also participate

in water activities in wading or swimming pools. I understand that water activities for children three

years of age and above may also include trips to the Chitimacha pool at the Recreation Department

on the reservation where an appropriate number of trained life guards and Yaamahana staff will be

on duty.

My child, ______________________, has permission to participate in any of the above supervised

age appropriate water activities while attending Yaamahana. I understand the center will take

precautions in providing for the safety of my child.

Parent/Guardian Signature:______________________________Date:________________

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Yaamahana/Chitimacha Child Development Center

Additional Information About My Child

What would you like us to know about your child that will help us in providing quality care?

Parent/Guardian Signature: ___________________________Date:___________________

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Yaamahana

Chitimacha Child Development Center

Parental Agreement

_____________________________

Child’s Name

Dear Parents,

Please read and sign this agreement:

I have been given a copy of the Chitimacha Child Development Center Family Handbook which

contains program and policy information. I hereby agree to comply with the rules and regulations

regarding fees, attendance, health, clothing, and other items specified in the Family Handbook.

I agree to keep all enrollment information updated (e.g. household income, telephone numbers,

address, designated adults allowed to pick up child, immunization records, etc.).

I further agree to notify the center of any change in my financial situation or changes which would

affect my ability to meet my financial obligation within 7 days.

Parent/Guardian Signature: ___________________________Date:___________________

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Yaamahana

Chitimacha Child Development Center

Weekly Tuition Rates

Full Day

$110.00/Week

Half Day

$55.00/Week

3 Days / Week

$66.00/Week

2 Days / Week

$44.00/Week

After School Care

$55.00/Week

• $50 yearly registration fee due at time of enrollment/re-enrollment

• $30 registration fee for pre-k Summer Care program only

• Sibling discount will be $2.00 per day.

• Yaamahana employee discount will be $2.00 per day per employee.

• Prices are subject to change depending on availability of funds.

Diaper & Wipes Rates

5 Days

$7.00 / Week

4 Days

$6.00 / Week

3 Days

$5.00 / Week

2 Days

$4.00 / Week

1 Day

$3.00 / Week

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Yaamahana

Chitimacha Child Development Center

SUPPLY LIST FOR QAKUN ROOM (Infants)

Please label all items with your child’s initials.

__ Unopened Can of Formula as needed

___ Enough clean, prepared bottles with caps/covers to last the day

___ Unopened Containers of baby food as needed

___ Extra pacifier to leave at center if needed

___ 2 complete changes of clothes

___ Shoes and socks each day

___ 1 box of tissues per month

___ Family poster

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Yaamahana

Chitimacha Child Development Center

SUPPLY LIST FOR KEESGI ROOM (1-Year-Olds)

Please label all items with your child’s initials.

___ Extra pacifier to leave at center if needed

___ 2 complete changes of clothes including socks

___ Child size toothbrush

___ Toothpaste as needed

___ Crib sheet and blanket for naptime

___ 1 box of tissues per month

___ Family poster

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Yaamahana

Chitimacha Child Development Center

SUPPLY LIST FOR NEXJUWA ROOM (2-Year-Olds)

Please label all items with your child’s initials.

___ 2 complete changes of clothes including underwear and socks

___ Child size toothbrush

___ Toothpaste as needed

___ Crib sheet and blanket for naptime

___ 1 box of tissues per month

___ Family poster

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

Yaamahana

Chitimacha Child Development Center

SUPPLY LIST FOR KAMCIN ROOM (3-Year-Olds)

Please label all items with your child’s initials.

___ 2 complete changes of clothes including underwear and socks

___ Child size toothbrush

___ Toothpaste as needed

___ Crib sheet and blanket for naptime

___ 1 box of tissues per month

___ Family poster

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Yaamahana

Chitimacha Child Development Center

SUPPLY LIST FOR COOTA ROOM (Pre-k)

Please label all items with your child’s initials.

___ 2 complete changes of clothes including underwear and socks

___ Child size toothbrush (Summer Care)

___ Toothpaste as needed (Summer Care)

___ Crib sheet and blanket for naptime (Summer Care)

___ 4 box of tissues per month

___ Family poster

Fill Online, Printable, Fillable, Blank YAM 2019-2020 Enrollment Packet For Tribal Members Final (Chitimacha Tribe of Louisiana) Form

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Fillable YAM 2019-2020 Enrollment Packet For Tribal Members Final (Chitimacha Tribe of Louisiana)

Fill Online, Printable, Fillable, Blank YAM 2019-2020 Enrollment Packet For Tribal Members Final (Chitimacha Tribe of Louisiana) Form

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