Enrollment form



Discovery Learning Center                        START DATE______________DIS-ENROLL DATE________________

FILE UPDATE:__________ / __________ / __________ / __________



______________________________________________________________________________________________________
Last Name,First,MDate of BirthSex: M / F

______________________________________________________________________________________________________
Last Name,First,MDate of BirthSex: M / F

______________________________________________________________________________________________________
Last Name,First,     M     Date of Birth      Sex: M / F

_____________________________________________________________________________________________________
Street Address City State Zip Code Home Telephone

Additional Schools/Programs attending while enrolled and grade:____________________________________________

With whom does the child live? Both Parents______Mother______Father______Other______

Father/Guardian Information Mother/Guardian Information

_____________________________________________    ________________________________________________
Last Name, First Last Name First

_____________________________________________    ________________________________________________
Street Address    Street Address

_____________________________________________    ________________________________________________
City State Zip Code   City State Zip Code

_____________________________________________    ____________________________________________
Home Telephone Home Telephone

_____________________________________________     ____________________________________________
Place of Work Place of Work

_____________________________________________     ____________________________________________
Work/Daytime Telephone Work/Daytime Telephone

_____________________________________________     ____________________________________________
Cellular Telephone     Cellular Telephone

_____________________________________________      ____________________________________________
Email Address Email Address


Please list two people locally who we could call on to be responsible for your child in the event of an illness, accident or
emergency, if neither parent/guardian can be reached. These individuals are also authorized to pick-up the child, if the parent is unable to be contacted:

_____________________________________________________________________________________________________
Name Street Address

____________________________________________________________________________________________________
City, State Zip Code Daytime & Evening Telephone

_____________________________________________________________________________________________________
Name Street Address

_____________________________________________________________________________________________________
City, State Zip Code Daytime & Evening Telephone

We require written permission or a phone call by a parent/guardian prior to releasing any child from our facility. (*The
child will be released to both parents unless appropriate legal paperwork is on file, and the custodial parent has made
an alternate request in writing.) We will require a photo ID for anyone picking up the child that normally does not.
ex: Grandma,Aunt, or friend.

Please list people that are not allowed to pick up child and turn in any necessary documents.

________________________________________________________________________________



I,__________________________________________________, being the natural parent or legal guardian of
(Child)______________________________________________________hereby give my permission for my child to be
given emergency treatment to include first aid and/or CPR by a trained and qualified staff member of Discovery Learning Center and/or local fire department, EMT. I will not hold Discovery Learning Center liable for any injuries that result from trying to ressessitate or help my child while injured. I further authorize and consent to medical, surgical, and hospital care, treatment and procedures to be performed for my child’s health in the event I cannot be contacted. I waive my right of informed consent to such treatment. I also give my permission for my child to be transported by ambulance or aid car to an emergency center for treatment should an accident or illness require immediate medical attention.



Physician’s Name___________________________________________________Phone_______________________________
Physician’s Address______________________________________________________________________________________
Clinic or Hospital Preferred:__________________________________________________Date of Last Tetanus_____________
Illnesses:_____________________________________________Blood type______________________

Medications:________________________________________________
List any allergies and any intolerances to food/medication or substance:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Action Plan: to take in any emergency situation regarding allergies or intolerances:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Does the child have any chronic illness, physical problems, health concerns or development issues?
If yes, please describe any accommodation needed.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________




Insurance Carrier______________________________________Subscriber’s Name___________________________________
Address_____________________________________________Subscriber’s ID Number_______________________________
City_______________________________State_____Zip______Group ID Number____________________________________

Office Use Only: Child’s Proof of Identity
Document used for verification_____________________________________________________________________________

Document Number:________________________________________________Date Issued:____________________________

Place of Birth_____________________________________________________Date of Birth:___________________________

Verification Signature_______________________________________________Date__________________________________

Discovery Learning Center Personal Record: to increase our understanding of your child’s personality and life
experience, please take a few moments to share the following information with us.

Has your child had any previous experience in a group care setting? NO______ YES______ if yes please describe

______________________________________________________________________________________________________

______________________________________________________________________________________________________
Please describe your child in the following:

Relating/interacting with other adults:_________________________________________________________________________

Relating/interacting with other children:_______________________________________________________________________

Separation from parents:__________________________________________________________________________________

Eating/Sleeping/Dressing:_________________________________________________________________________________

Times that your child finds stressful or difficult:_________________________________________________________________

Personality:_____________________________________________________________________________________________





Please call the center by 8am if your child will not be attending on his regularly scheduled day.
I hereby grant permission for my child to participate in any and all of the child care activities and to use any of the
equipment to include all indoor and outdoor toys, swings, slides, blocks, scissors, climbing structures etc. Discovery
Learning Center is not responsible for any accidents that occur while my child is playing on such equipment.
Initial ___________
  • You will be notified of every fieldtrip your child will participate in away from the center. Please leave a carseat.
Authorization to treat Minor Injuries or Accidents
I hereby authorize Discovery Learning Center faculty to administer medical treatment and or first-aid for any minor
injury or accident while my child is in their care and hold Discovery Learning Center harmless.
Initial ___________


I understand that my child cannot attend Discovery Learning Center when ill. I authorize the center to contact me in
the event my child becomes ill while in attendance. I agree to pick-up my child or make arrangements for an authorized
individual to pick up my child within 1 hour of receiving notification. The state requires a child needs to go home
within the hour if he has a fever of 100 degrees or greater or has 2 runny stools in an hour that cannot be contained
within the diaper. Please refer to Parent handbook for state guidelines regarding illnesses.


I understand that I must notify Discovery Learning Center in the event that a communicable disease occurs within my immediate family.
For example Ringworm, Streptococcus, Scabies, Chicken Pox and Lice could be hazardous to our child care population. I understand my child cannot attend the center until all symptoms are gone and a Doctor’s note clearly states my child is
no longer contagious and can return to Discovery Learning Center. Please refer to Parent Handbook for regulations.


In the event that you privately contract for child care services, transportation, or assistance with any Discovery Learning
Center employee, Discovery Learning Center will neither be held responsible nor liable for any accidents, injuries, or
other incidents arising there from. I agree to hold harmless Discovery Learning Center from any and all legal action
arising for any independent child care or other arrangement with Discovery Learning Center employees.


In the event that Discovery Learning Center has reason to suspect the occurrence of physical, sexual or emotional abuse,
neglect, or exploitation of a child. Discovery Learning Center will, as required by South Dakota Department of Child
Care Services report the incident immediately to The Department of Child Care Services Division of Child Protection
Services.


I give permission for emergency care decisions to be made by the Discovery Learning Center staff regarding my child in
the event of an emergency that impedes regular center operations and will hold Discovery Learning Center harmless.

Initial here______________


After a child has been continually enrolled for a period of 4 weeks, the child is entitled to 10 free days if full-time or 5 days
if part-time with no tuition due to maintain their enrollment. Parents must notify director two weeks in advance of their intention to use free days. Please refer to the Parent handbook for rules and regulations regarding free days.
Free day slips are provided on the parent information board or in the office. Free day slips are turned in with tuition.
*Regular tuition rates will apply to all days absent beyond allowed free days.
I have read, understand and agree to the above authorizations.

Parents/Guardian Signature____________________________________________________Date_______________________



Discovery Learning Center is open 6:30am—6:30pm, Monday through Friday year round. We are closed for the following paid holidays :Labor Day, Thanksgiving Day, Christmas Day, New Year’s Day, Memorial Day and Independence Day.

In consideration of our faculty, Discovery Learning Center will close each year at 3:00pm on Christmas Eve &
New Year's Eve.

In the unlikely event that Discovery Learning Center will close for inclement weather, we will announce closing on
KELO 92.5 radio. Please listen to local radio and television for closings. We will contact you if the severity of the weather
dictates an early closing.



Tuition is charged for the week your child is attending. Tuition is based on your enrollment at Discovery Learning Center
not based on your child’s attendance. Regular tuition will apply to all days absent beyond allowed free days.

PLEASE INITIAL______.

Tuition is due each week on Monday. If tuition is not received before the close of business
on Monday, a late fee of $20.00 will be assessed. Children may be denied access to the center if payments are
overdue.
Payments should be made by cash, local check, money order or cashier's check.



Discovery Learning Center charges $30.00 for each returned check. Parents are expected to replace returned checks with
2 days of notification by their bank or Discovery Learning Center. Discovery Learning Center will require payment be
guaranteed funds in the event 2 checks are returned within a calendar year.



I hereby request that my child(ren),__________________________________________________ be permitted to participate
in field trips outside of the center for his/her benefit in attendance at Discovery Learning Center. Initials _____________


I give Discovery Learning Center permission to administer the following medication,______________________________

to my child(ren),__________________________________________.

Parent Signature________________________________________________.



Discovery Learning Center charges an initial non-refundable fee of $25.00 per family. This non-refundable fee is
applicable to parents wishing to hold a spot in our facility until an opening is available and/or expectant parents.

Multi-Child Discount
Discovery Learning Center offers a 20% tuition discount for additional siblings,  taken off the lowest tuition rate.

Late Pick Up
Discovery Learning Center closes each day at 6:30pm.   Late pick-up fees of $1.00 per minute will be incurred whenever
pick-up is made after closing. Incurred late fees are immediately due. If no one listed on the child’s enrollment forms
responds to our telephone calls, the local police and or Department of Social Services will be notified exactly one hour
after closing.

Disenrollment
Discovery Learning Center reserves the right to disenroll for non-payment, failure to follow policies, and in the event of
behavior issues.

Withdrawal From Discovery Learning Center
Parents are required to give two weeks written notice of their intention to withdraw their child from the center.
Without such written notice, parents are liable to pay the center for two weeks tuition, late fees, collection fees
and reasonable attorney fees.

Initial here:_______________



I have read, understand and agree to all of the agreements and authorizations listed above, and I
am fully able to grant these authorizations/agreements, as the parent or legal guardian, of the child
listed previously in this forms. I do voluntarily make these authorizations and agreements as listed
above with Discovery Learning Center.

______________________________________________________________________________________________________
Parent/Guardian Signature Date Tuition Rate


______________________________________________________________________________________________________
Director’s Signature Date   Start Date
Place your photo here.
For your convenience parents can print enrollment forms. Please call Discovery for availability and an appointment for enrollment. Please bring:
  • A current copy of your child's immunization record
  • Registration fee of $25

Upon enrollment a Parent Handbook will be given to you and an "About My Child" form to give us more detailed information about your child's personality and needs. You will also be given a  menu, class schedule, list of classroom supplies, security entry code, and your child's classroom activity calendar & attendance calendar for the current month.
CHILD'S INFORMATION:
EMERGENCY CONTACTS
ENROLLMENT AUTHORIZATIONS/PARTICIPATION PERMISSION
PHYSICIAN INFORMATION
EMERGENCY MEDICAL AUTHORIZATION
MEDICAL INSURANCE INFORMATION
ILLNESS NOTIFICATION & PICK-UP
COMMUNICABLE DISEASE
PRIVATE CARE EXCLUSION
SOUTH DAKOTA DEPARTMENT OF CHILD PROTECTIVE SERVICES
EMERGENCY CARE AUTHORIZATION
FREE DAYS/VACATION DAYS
ENROLLMENT AGREEMENT
TUITION
RETURNED CHECKS
REGISTRATION FEE
Welcome! Thank you for Discovering the difference!
*This is a sample of our policies. Please refer to our Parent Handbook for detailed Rules and Regulations with State guidelines for our center from the South Dakota Department of Child Care Services.
(605) 274-3475  We will see you soon!
Discovery Learning Center in Sioux Falls, SD (605) 274-3475Website created by Lissa Hoxsie
FIELDTRIP  PERMISSION
MEDICATION ADMINISTRATION