Download Little MavericksLearning Center

Little Mavericks Learning Center
Fall Semester
Spring Semester
(circle one)
Child’s Name: _______________________________ Birth Date: ________________________ Gender:_____________
Parent/Contact Person: ________________________________ Day Time Phone Number: _________________________
Fall/Spring Application
Address: __________________________________________________________________________________________
Street Address (no P.O. Box)
City/State
Zip
E-Mail: ______________________________________________________________________
Schedule
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Times your child will be at Little Mavericks (i.e. 8:00am-5:00pm)
Minimum days required: Two full days (more than 5 hours) or three half days (under 5 hours)
Toddlers need to be dropped off before 11:45am or after 2:30pm
Little Mavericks is open from 6:45 qm-5:30pm Monday-Friday
M_______________________
T_____________________
W_______________________
H_____________________
F________________________
My child has a sibling that I will be turning in a separate application for_______________________________________
(Sibling’s name and birth date)
I am a
Mesa State Student
Faculty Staff member
Mother’s 700#______________________________
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Community (LMLC must serve Student and Faculty first)
Father’s 700#______________________________
A $30 NON-REFUNDABLE application fee, for each child, is required at the time of acceptance into the
program.
Mail application to Little Mavericks, 1100 North Ave, Grand Junction, CO 81501
If my child is not accepted into the program, my application(s) will be kept on file until the end of the school
year as part of LMLC’s waiting list.
_______________________________________
Parent Signature
Office Use Only
Date Registration fee paid: _________________
Check #_______________ Cash: _____________
Comments:
_______________________
Date
LITTLE MAVERICKS LEARNING CENTER
All items must be completed and turned in at registration. A complete enrollment packet is required
for all children attending Little Mavericks. This includes new and all returning children.
 Toddlers must be at least 1 year old and walking
 Preschool children must be at least 3 years of age and fully potty trained. No pull ups
or diapers allowed on the preschool side
Check List
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Enrollment Packet to be completed after acceptance into the program
Doctors note stating your child is healthy and can attend school
Copy of immunizations
CMU class schedule
Little Mavericks Learning Center
Enrollment Packet
Child’s Name_____________________________________ Birth Date_____________________ Gender_____________
Address_______________________________________ City________________________________ Zip_____________
Child Information and Medical Information
Name(s) and age(s) of siblings: ________________________________________________________________________
Mother’s Name: _______________________________
Father’s Name: ____________________________________
Birth Date____________________________________
Birth Date:_______________________________________
Social Sec #_________________________________
Social Sec #______________________________________
Address: _____________________________________
Address: _________________________________________
Phone #______________________________________
Phone #__________________________________________
Employer: ____________________________________
Employer: ________________________________________
Address: _____________________________________
Address: _________________________________________
Phone #______________________________________
Phone #_________________________________________
CMU 700#____________________________________
CMU 700 #______________________________________
Custody issues or concerns:
If there are custody issues involving your child, Little Mavericks must have copies of court papers.
Health History
Describe any surgeries, accidents, chronic illnesses or handicapping conditions.
Allergies: _____________________________________________________________________________________
Food Restrictions: _______________________________________________________________________________
Physician’s Note (Statement of health Signed by Physician)
I find _______________________________to be in good health and able to attend Little Mavericks Learning Center
.
Are there restrictions to the child participating in any activities? If yes, please describe.
_____________________________________________
Physician’s Signature
_______________________________
Date
Please attach a copy of your child’s immunization records
Non Parent Emergency Contacts
Please list the persons you would like contacted (in order of priority) if you cannot be reached in case of emergency. For
the safety of your child, we will request all authorized release persons with whom staff are not familiar to provide
Government-issued photo identification at the time of pick-up.
Persons listed below are authorized to pick up the child in case of a campus wide or building evacuation. These persons
will also be called in if the parent cannot be reached during the school day if the child needs picked up for any reason.
Contacts must live locally
Emergency Contact Information
Name: _________________________________ Phone #___________________Relationship:______________________
Name: _________________________________ Phone #___________________Relationship:______________________
Name: _________________________________ Phone #___________________Relationship:______________________
Name: _________________________________ Phone #___________________Relationship:______________________
Name: _________________________________ Phone #___________________Relationship:______________________
Your child will not be released without prior written authorization to anyone not listed above. In the event you call a pickup authorization into the school because you are unable to submit your authorization in writing, we will use your personal
information from this packet to verify your identity.
_______________________________________________
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Parent’s Signature
Date
Authorization to Treat a Minor
This consent shall remain effective until ________________, of the year __________.
Medical Authorization
I (we) the undersigned parent, parents or legal guardian of __________________________________, a minor, do hereby
authorize and consent to any x-ray examination, anesthetic, medical or surgical diagnosis rendered under the general or
special supervision of any member of the medical staff and emergency room staff licensed under the provision of the
Medicine Practice Act, of a Dentist licensed under the provisions of the Dental Practice Act, and on the staff of any acute
general hospital holding a current license to operate a hospital from the State of Colorado Department of Public Health. It
is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care being
required but is given to provide authority and power to render care, which the aforementioned physician in the exercise of
his best judgment may deem advisable. It is understood that effort shall be made to contact the undersigned prior to
rendering treatment to the patient, but that any of the above treatment will not be withheld if the undersigned cannot be
reached.
List any restrictions:
Signature of Father, Mother, or Legal Guardian:
_______________________________________________________Date: _____________________
_______________________________________________________Date: _____________________
Child’s Birth Date: _________________________________
Last Tetanus Booster: ____________________
Allergies to Drugs or Food:
_________________________________________________________________________________
Any Special Medications or Pertinent Information:
_________________________________________________________________________________
_____________________________________________________
Preferred Hospital: _____________________________________Phone:_______________________
Child’s Physician: ______________________________________Phone:_______________________
Insurance Company: _________________________________________________________________
Policy Number: _______________________________________
Please read and initial each item in the box, then sign at the bottom.
Video Release
I understand the use of video is limited to those of educational quality and those that are age
appropriate. Videos are used for teaching purposes, special occasions and during bad weather. On
occasion full length children’s movies are viewed.
Nap Cot Authorization
I have discussed the nap routine with the staff and I have seen the cot/mat my child will sleep on. I
hereby give permission for my child to use the cots during nap time.
Field Trip
I understand that the children take walking field trips around campus. If field trips take children away
from campus, I will be notified and a special permission slip will be provided.
Authorizations
Sun Screen
I understand that sunscreen will be applied only with written authorization and instructions for
application. I will provide LMLC with sunscreen that is labeled with my child’s first and last name
along with Instructions for application.
Tuition Payment
I understand that tuition is due by the 15th of each month. Failure to pay my tuition will result in
termination of services for my child.
Permission Releases
I hereby grant permission for my child _____________________________ to participate in all activities at
Little Mavericks Learning Center. These will include, but not be limited to, field trips and walks, cooking experiences,
evaluations, videotaping of classrooms, publicity photos connected with the program, and use of all play equipment in the
building.
I also understand the school will not be responsible for anything that happens as a result of false information
given at the time of enrollment. I understand the school will not be held responsible for a child who has not been signed
in when he/she arrives for the day.
In consideration of Little Mavericks Learning Center admitting my child into its program, I hereby for myself,
my heirs, administrator and assign, waive and release any and all rights to and claim of any nature against LMLC and
their organization, representatives, successors and assign for any and all injuries or damages of any nature which my child
may suffer in the program.
I also acknowledge that I have read and agree to the policies set forth in the Parent Handbook.
______________________________________
Parent signature
______________________________
Date
Tuition
Tuition is billed at the beginning of the month and due on the 15 th of the month. The exception is the first month of the
semester, which is included with the second month’s bill and is due on the 15 th of the second month. For example, August
and September are billed Sept 1st and due Sept 15th, similarly, January and February are billed Feb 1 st and due February
15th.
Delinquent accounts are daycare accounts that have a balance remaining after day care tuition is due.
If a balance remains after the 25th of the month tuition is due, a child will no longer be able to attend Little Mavericks
until the balance is paid off.
Any account that goes without a payment for 90 days will be sent to collections.
Late fee:
Late payment will result in a fee of $5.00 per day for each day after due date.
Tuition Agreement
Return checks:
A $22.00 charge added to your account.
Late pick up:
All children must be picked up by 5:30pm. Little Mavericks charges a late fee of $5.00 for every fifteen minutes a child
remains at the center past the deadline. The fee will be added to their next tuition bill.
By signing this agreement, I am stating that I have read and agree to all tuition
policies and procedures of Little Mavericks LEARNING CENTER.
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Parent’s signature
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Date