Creative Learning Preschool and Childcare Center, Inc.


Office Use Only:
Student Information----------------------------------------------------------------------------------------------------------------------
Child’s Name:
Today’s Date
Child’s Address:
Prior childcare centers attended:
Student’s Doctor:
Student’s Dentist:
Parental Guardian Information -------------------------------------------------------------------------------------------------------------
Mother or Guardian Name
Father or Guardian Name
Place of Employment
Place of Employment
Home Phone
Home Phone
Work Phone
Work Phone
Cell Phone
Cell Phone
The following information will help our staff become aware of your family structure so that we can respond to your needs and the needs of your child.

Child resides with:
Parent’s Marital Status:
Are there custodial arrangements for your child that you would like us to know about? If yes, please explain:
Emergency Information ----------------------------------------------------------------------------------------------------------------------
The child will be released to the persons signing this form. The people listed below can also pick up the child in case of an emergency or when the parent or guardian cannot be reached.

Phone Number
General Information ----------------------------------------------------------------------------------------------------------------------
My child is allergic to the following:
My child has the following special needs:
Describe child’s past illnesses:
My child is on the following medications:
Reason for the medication listed above:
My child’s likes are:
My child’s dislikes are:
Please share with us the reason why you were attracted to Creative Learning Preschool and Childcare Center:

I hereby give Creative Learning Preschool and Childcare Center it’s agents, and employees permission to secure whatever emergency measures that are deemed necessary for the protection of my child while he/she is in their care. I understand that the authorization includes, but is not limited to calling a physician or other emergency services, implementing their instructing and transporting my child to a hospital or clinic without first obtaining my consent. In the event of a mandatory evacuation the staff will evacuate the children by foot through a back gate to Mendez’s Seafood Bar & Grill on Doucet St. which is the next street over. If, in the event, the child should need emergency medical care, Creative Learning Preschool and Childcare Center Inc. will call an ambulance to bring the child to the hospital.

Signature of Mother or Guardian
Signature of Father or Guardian
Creative Learning Preschool and Childcare Center, Inc. welcomes students of any race, gender, religion, and ethnic origin.
“Individual Excellence through the Joy of Learning”
Parental Agreement

1. Creative Learning Preschool and Childcare is an equal opportunity employer. No person will on the basis of race, color, or national origin, be excluded from participation in, be denied for or be otherwise subject to discrimination under any program.
2. I agree to pay tuition fees in advance with no deduction for holidays or when my child is absent or unable to attend. I understand that tuition that is not paid in advance will be subject to penalty and a late charge of $10 per day for a max of 7 days. In the even that my account becomes 7 days past due, my child will be unable to return to Creative Learning Preschool and Childcare Center until my account is brought current. I understand that if I am asked to remove my child from enrollment for a second time due to non-payment of tuition that my child will not be eligible for re-enrollment. I understand that when the tuition becomes 45 days past due and no satisfactory arrangement has been made with the business office to pay the outstanding balance, that the account will be turned over to an agency for collection and that I will be responsible for all outstanding balances, penalty fees, and collection fees. I have elected to pay tuition fees (check one):
3. I agree to pay Fall and Summer registration fee every year that my child is enrolled in the program. Summer Registration is due by April 15 th and Fall Registration is due by July 15 th .
4. I agree to pay $50 for any return check. I understand that Creative Learning Preschool and Childcare Center may request that all tuition payments be made by money order or cash once a check has been returned.
5. Current tuition for my child upon date of enrollment is $ (see above for payment option chosen) I understand that Creative Learning Preschool and Childcare Center reserves the right to increase tuition rates, but that I will be provided with a 30-day notice in advance of any increase in tuition.
6. I agree to give the school a two-week written notice in case of withdrawal of my child from the school. I will give this written notice to a staff member in the office. Verbal notification to my child’s teacher is not sufficient. If the notice is not given, I agree to pay two weeks’ tuition plus whatever tuition is due at the time.
7. In the event of an emergency, the school has my permission to administer first aid or obtain emergency medical treatment, which, in the sole discretion of the school, is in the child’s best interest.
8. If the director of the school determines that my child cannot adjust to the center’s program after all behavioral techniques have been utilized the child will be withdrawn and this agreement will be terminated.
9. I agree to pay a late pick up fee of $2.00 per minute that my child is left at school after 5:46 pm and $5.00 per minute after 5:51 pm.
10. In the event that it becomes necessary for the school to retain the services of an attorney to enforce any of the provisions of this agreement and/or to defend any legal action brought by me for whom the school is eventually absolved liability. I agree to pay the reasonable attorney fees incurred by the school.
Signature of Parent or Guardian
Creative Learning Preschool and Childcare Center Authorized Staff Member
Parental / Guardian Information
The guardian/parent who signs the Parental Agreement must fill out the following information:

Parent / Guardian\’s Name:
Physical Address:
Billing Address if different from physical:
Home Phone:
Cell Phone:
Driver/’s License Number:
Social Security Number:
Date of Birth:
Place of Employment:
Work Address:
I understand that Creative Learning Preschool will keep all personal information confidential. This information will only be used for credit purposes and in attempts to recover outstanding balances owed to Creative Learning Preschool.
Signature of Parent/Guardian
Student Master Card
 Child’s Name:  
Home Phone
Work Phone
Cell Phone
Person with whom the child lives:
Child’s Doctor:
Phone Number:
Child’s Dentist:
Phone Number:
Individuals to contact in case of emergency and also to whom my child may be released:
Phone Number
Does your child have any food allergies?   Yes or No
Does your child have any other allergies?   Yes or No
Does your child have any dietary restrictions?   Yes or No
If yes, please explain here:
I authorize the center to secure emergency medical treatment for my child.
Signature of Parent/Guardian
Date of Admission