The WCADCC Enrollment form - English | The West Chester Area Day Care Center

Step 1 of 5

Completion of this agreement is required to enrollment. This form will enable us to better understand your child and meet his/her needs. Much of the information requested is necessary to comply with the state child care licensing regulations.

Enrollment Information

Child's Enrollment Start Date(Required)

Birthdate(Required)

Child's name(Required)

First Last

Child's nickname

Age(Required)

Gender(Required)

Male

Female

Child's primary language(Required)

Parent/guardian/sponsor primary language(Required)

Child's Address(Required)

Street Address City State ZIP Code

Family Information

List family members and pets your child lives with - Include first names, relation and ages of siblings

Name(Required)

Relation(Required)

Age of siblings(Required)

Parent/guardian/sponsor(Required)

First Last

Relationship to child(Required)

Home Phone(Required)

Cell Phone(Required)

Home Address(Required)

Street Address City State ZIP Code

Home Email(Required)

Work Email(Required)

Work Phone

Employer(Required)

Employer Address(Required)

Street Address City State ZIP Code

Other parent/guardian/sponsor(Required)

First Last

Relationship to child(Required)

Home Phone(Required)

Cell Phone(Required)

Home Address(Required)

Street Address City State ZIP Code

Home Email(Required)

Work Email(Required)

Work Phone

Employer(Required)

Employer Address(Required)

Street Address City State ZIP Code

Child Emergency Contact and Release Information (do not include parents/guardians/sponsors)

Please notify the center if an Emergency Release Contact will pick up your child on a given day. ( For the safety of your child, we request that all authorized pick up persons with whom staff is not familiar provide a photo ID at the time of pick up.)

Name(Required)

Relationship to child(Required)

Phone(Required)

Address(Required)

The persons designated in this section will be contacted by us if you cannot be reached in the event of a medical or other emergency. Our staff will only release your child to you or to those persons listed above. If you want a person who is not identified above to pick up your child, you must notify our staff in advance, in writing. Your child will not be released without prior authorization.

Parent's Name(Required)

First Last

Parent's signature(Required)

Other Agreements

Child's Name(Required)

First Last

Birthdate(Required)

Walking Excursions(Required)

I give my permission for my child to participate in supervised walking excursions near and around the center.

Media Release(Required)

Approval to post photos. I authorize the use and reproduction of photographs of my child in conjunction with the WCADCC program.

Refusal to post photos. I DO NOT WANT my child's photos posted, published, shared, used or reproduced publicly in newspapers or on any websites in conjunction with the WCADCC program.

Occasionally, photos will be taken of the children at the center for use within the center or on our website and/or newsletters. Please indicate if you authorize the use and reproduction of photographs of your child in conjunction with the program.

Handbook Acknowledgement(Required)

I understand and agree that it is my responsibility to read and familiarize myself with policies and procedures outlined in the Family Handbook and agree to abide by them.

I understand that it is my responsibility to go directly to management with any questions I may have regarding the policies and procedures and information contained in this Enrollment Agreement.

I understand information contained in the Family Handbook may be subject to change.

I agree to keep all contact information, Including emergency contacts, up to date.

Contract Approval

I certify that I have read, understand, and accept all of the terms and conditions described in this Enrollment Agreement.

Primary Parent/Guardian/Sponsor Signature(Required)

Non-Discrimination Statement

In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA), civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex, disability, age, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA.

Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.

To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) found online at: http://www.ascr.usda.gov/complaint_filing_cust.html, and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by:

1) Mail: U.S. Department of Agriculture
Office of the Assistant Secretary for Civil Rights
1400 Independence Avenue, SW
Washington, D.C. 20250-9410;
2) Fax: (202) 690-7442; or
3) Email: program.intake@usda.gov

Contact Information:
www.wcadaycare.org
610-696-8447
610-696-0461(fax)
wcadcc@gmail.com

Our Mission Statement:
The West Chester Area Day Care Center is non-profit childcare program that provides a quality, early childhood education program that promotes the development of children emotionally, socially, intellectually, and physically in a safe and nurturing environment. We offer all parents affordable childcare with special emphasis on those with the greatest financial need.

* This institution is an equal opportunity provider.

The WCADCC Enrollment form – English

Enrollment Information

Family Information

Child Emergency Contact and Release Information (do not include parents/guardians/sponsors)

Medical Information

Child's Medical Care Provider

Child's Insurance Provider

Medical Information (continued)

Child's Medical & Developmental History

Other Agreements

Contract Approval

Non-Discrimination Statement

Rate Agreement

Hours of Operation

Scheduled Attendance

Fee Policy (paren/guardian/sponsor is to review and initial each line)

Other Agreements

info@wcadaycare.org

610-696-8447

501 East Nields St.
West Chester, PA 19382

The WCADCC Enrollment form – English

Enrollment Information

Family Information

Child Emergency Contact and Release Information (do not include parents/guardians/sponsors)

Medical Information

Child's Medical Care Provider

Child's Insurance Provider

Medical Information (continued)

Child's Medical & Developmental History

Other Agreements

Contract Approval

Non-Discrimination Statement

Rate Agreement

Hours of Operation

Scheduled Attendance

Fee Policy (paren/guardian/sponsor is to review and initial each line)

Other Agreements

info@wcadaycare.org

610-696-8447

501 East Nields St.West Chester, PA 19382

501 East Nields St.
West Chester, PA 19382