Author: Caren Eaton

Bite-Sized Daycare

School _______________________________

Enrollment Date: _______________
Withdrawal Date: _______________

Child’s Name ______________________ Nickname __________ Date of Birth _________ Sex ____

Mother/Father/Guardian Information
(List only individuals who have legal custody of child. If mother is not listed, or if guardian is not a parent, legal proof of custody must be provided.)
Name ________________________________________________________ SSN _________________________________
Home Address ___________________________________ City _____________________ State ______ Zip ___________ Home Phone _____________________ Cell Phone ______________________ Work Phone ____________________
Employer _______________________________ Email Address _____________________________________________
Employer Address ____________________________________________________________________________________
Mother/Father/Guardian Information
(List only individuals who have legal custody of child. If father is not listed, or if guardian is not a parent, legal proof of custody must be provided.)
Name ________________________________________________________ SSN _________________________________
Home Address ___________________________________ City _____________________ State ______ Zip ___________ Home Phone _____________________ Cell Phone ______________________ Work Phone ____________________
Employer _______________________________ Email Address _____________________________________________
Employer Address ____________________________________________________________________________________

EMERGENCY CONTACT INFORMATION
Persons authorized to pick-up the child daily: ____________________________________________________________
Persons to be contacted in case of illness, accident or emergency and authorized to pick-up the child from the school if the parents or guardians cannot be reached. (Minimum of 2 required)
___________________________________________________________________________________________________________
Name Street , City, State Phone Relationship
___________________________________________________________________________________________________________
Name Street, City, State Phone Relationship
Child’s Physician Phone _____________________________
Child’s Dentist Phone _____________________________
List allergies and intolerance to foods, medications or other substances _______________________________________
Action to be taken _______________________________________________________________________________

AUTHORIZATION FOR EMERGENCY MEDICAL CARE
If I cannot be contacted in an emergency situation, I authorize the center’s staff to obtain emergency medical treatment for my child.
Signature of Parent/Guardian ______________________________________ Date ________________

PHOTO RELEASE
_____ I give permission for photos of my child to be used by Bite-Sized Daycare, for purposes to include but not limited to Constant
Contact Emails and Newsletters, the Bite Sized Daycare website, social media, ads, flyers, brochures, videos and for other marketing purposes.
_____ I do not wish for photos of my child to be taken and used for any of the above purposes.
Signature of Parent/Guardian ______________________________________ Date ________________

03/2022

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Child’s Profile

Family
Mother’s Occupation Father’s Occupation
Other family members (brothers, sisters, grandparents, etc.) living at home:
NAME AGE RELATIONSHIP
Other family members living in the community:
NAME AGE RELATIONSHIP

Health
What communicable diseases has the child had? Measles (Big Red) Measles (3 day)
Mumps Chicken Pox Whooping Cough Other
Any chronic physical problem?
Type of accommodations needed*:
Any developmental or learning need? _______________________________________________________________
Type of accommodations needed*: _______________________________________________________________
* If special accommodations are needed, a current copy of the child’s IEP or ISP is required.
Medications
Are any medications given regularly? (Please list medications and reasons) _________________________________
______________________________________________________________________________________________
Brand of infant formula (if applicable): _________________
Speech
Describe your child’s speech: Rapid ___ Slow ___ Moderate ___ Clear ___ Talks Constantly ___ Seldom Speaks ___ Uses Many Words ___ Uses Few Words ___ Talks Only During Play ___
Toileting
Does your child have any special toileting needs? If so, please explain:
Sleep Patterns
What time does your child go to bed? Awaken? ______ Does he/she walk, talk or cry out at night? _____
Does he/she take anything to bed with them? What is his/her mood upon awakening? __________________
Does he/she take naps? Typical time of nap: __________________________________

Please note: It is Bite Sized Daycare’s policy to feed infants on demand unless other written instructions are on file from the child’s physician.

Interests
Has he/she had experience playing with other children? __________________________________________________
With what age child does he/she prefer to play? ________________________________________________________
What are his/her favorite activities at home? ___________________________________________________________
_______________________________________________________________________________________________
Does he/she like to: Be read to? ___ Listen to music? ___ Play outdoors? ___
Can he/she ride a tricycle? ___
Has he/she had experience with: Clay? ___ Scissors? ___ Easel Painting? ___
Blocks? ___ Puzzles? ___ Finger Painting? ___

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Child’s Profile (con’t)

Schooling
Please list any previous school and/or child care center enrollment:
______________________________________________________________________________________________
Name of school/child care center City/Town State Date
______________________________________________________________________________________________
Name of school/child care center City/Town State Date
Is your child attending another school concurrently with our program?
Name of School Grade or Class Level

Comments
In what particular ways can we help your child this year?
Describe your child briefly (personality, abilities, etc.)

Financial Agreement
I _________________________ (please print name), the parent/guardian of ___________________________________ agree to pay my child’s tuition no later than Monday of the current week. If I have not paid by Wednesday of the current week, I understand that I will be charged a late fee. I also understand that if I do not pick my child up by the center’s closing time, I will incur a late pick up charge . In the event that my child’s tuition account becomes two weeks in arrears, I understand that my child care services with Bite-Sized Daycare will be terminated. I also agree to pay all costs and expenses including, without limitation, court costs, reasonable attorney fees and reasonable collection agency fees incurred by Bite-Sized Daycare in connection with the collection of tuition and the enforcement of this agreement. I understand that Bite-Sized Daycare and its authorized agents will use any personal contact information (home, work, cell and emergency contact numbers) provided to us on this document in an attempt to collect any outstanding balance on the account.
_______________________________________ _________________________
Mother/Guardian Signature Date
_______________________________________ _________________________
Father/Guardian Signature Date

Hold Harmless Agreement
I _________________________ (please print name), the parent/guardian of ____________________________________ agree to
release and hold harmless Bite-Sized Daycare and its employees, from any accident or harm that may occur should I retain the
services of any Bite Sized Daycare employee for the care of my child(ren) outside the child care center. I understand that Bite-Sized Daycare does not condone or encourage its employees to babysit for parents of enrolled children outside of the child care center. If I retain the services of any Bite-Sized Daycare employee in such capacity, Bite-Sized Daycare has no responsibility and is held harmless from any incident which may occur.
_______________________________________ _________________________
Mother/Guardian Signature Date
_______________________________________ _________________________
Father/Guardian Signature Date

Identity Verification For Office Use Only
Place of Birth: ___________________________________________ Birth Date: __________________________
Birth Certificate Number: __________________________________ Date Issued: ___________________________
Other Form of Proof: _____________________________________________________________________________
Director/Assistant Director Signature: ________________________________________________________________

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Bite-Sized Daycare Policies

I understand that my child must not be left on school grounds without supervision. I agree to walk my child into the school each morning and release my child to a teacher before leaving my child.
I understand that all required forms must be completed and on file at the center before my child may attend.
I understand that no child may be released to anyone except parents/guardians without written permission. I understand that Bite Sized Daycare will release children to either parent unless a court order indicating sole custody is provided to the center Director. I agree to give to the center a list of all persons authorized to pick up my child.
I understand that no medication will be administered without written permission from parents.
I agree to support and reinforce the school’s rules and procedures that concern the health and safety of my child and other children.
I understand that the Director will notify me whenever my child becomes ill and I agree to pick-up my child or make arrangements to have my child picked up by an authorized individual within one hour of notification.
I understand that my child cannot attend the school if he/she has any illness that threatens the health of other children. I understand that Health Department regulations concerning periods of infection will be enforced. I understand that my child must be fever and symptom free for 24 hours before returning to school after an illness. I also understand that prescription medication must be administered to my child at home for 24 hours before he or she can return to school.
I understand that I am required to inform the center within 24 hours or the next business day if my child or any member of my immediate household has developed any reportable communicable disease, as defined by the State Board of Health, except for life threatening diseases which must be reported immediately.
I understand that child care services may be terminated for any of the following reasons:
My child’s tuition account becomes more than two weeks in arrears.
Failure to respond in a timely manner when contacted by the center to pick my child when he or she is sick.
Failure to adhere to the 24 hour illness recuperation period.
Failure to notify the center, in advance, if my school age child will not be attending after-school care.
Failure to provide the center with up-to-date emergency contact information for my child.
Bite-Sized Daycare does not receive parental support and help if my child is found to have a learning or behavioral problem. This includes failure to attend parent conferences and to follow through with medical and/or educational specialists.
My child’s behavior pattern threatens his or her own health and safety or threatens the health and safety of other children and staff.
Parents/guardians are no longer supportive of Bite-Sized Daycare’s program and philosophy and become negative and uncooperative in their actions and opinion which may undermine the operation of the school.
Parents who are repeatedly late will be asked to make other child care arrangements.
Please Read and Sign:
I have read the policies in the Bite-Sized Daycare Family Handbook and understand their application to me and my child.
Mother/Guardian Signature ______________________________________ Date ________________________
Father/Guardian Signature _______________________________________ Date ________________________
Director’s Signature ____________________________________________ Date ________________________

03/2022

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