GARTLAND CHILD DEVELOPMENT CENTER, INC.
CHILD’S APPLICATION
Pre-screening Date of Center/ Home (____________________)
Date of Admission of Child (___________________)
Child’s Full Name___________________________________________
Child’s Date of Birth (________________) Child’s Age ___________
Home Address _____________________________________________
City ____________________________, TN Zip Code_____________
Home Phone #________________Parent’s Work #_________________
Name of the School Child Attend(s)______________________/______
(grade)
Parent Information:
MOTHER’S NAME; WORK NUMBER; EMPLOYER;
EMPLOYER’S ADDRESS; WORK HOURS
MOTHER’S INFORMATION
NAME:
FATHER’S NAME;WORK NUMBER;EMPLOYER
EMPLOYER’S ADDRESS; WORK HOURS
FATHER’S INFORMATION
NAME:
EMPLOYER’S NAME
EMPLOYER’S NAME
EMPLOYER’S NUMBER
EMPLOYER’S NUMBER
EMPLOYER’S ADDRESS
EMPLOYER’S ADDRESS
WORK HOURS:
WORK DAYS:
WORK DAYS:
WORK DAYS
CELL NUMBER:
(615)
CELL NUMBER:
(615)
EMERGENCY INFORMATION: (In Case of Emergency)
Name of Doctor/Physician__________________________/ Office #_____________________
Address of Office:_______________________________________________________________
A Person Authorized to Act for the Parent:_________________________________________
(Name) /Relationship
Employer Address__________________________Employer #__________________________
Hm Address____________________________/ Hm Number___________________________
Work Hours____________________________/Cell # _________________________________
Transportation Plan:
Person(s) authorizes to provide transportation for your child
(Name and relationship to the child)
1. _____________________________________/ 2. _________________________________
3. _____________________________________/ 4. _________________________________
PAGE 2
BACKGROUND INFORMATION
CHILD’S APPLICATION
Family members (other children)
birthdates
ages
(what ?) school
Eating Habits:
At what time does the child eat: Breakfast? __________ Lunch __________ Dinner__________
Does your child feed him/herself? Yes_________ No___________
What is the Child’s Attitude toward eating? __________________________________________
Favorite Foods ___________,_____________, ______________.
Disliked Foods or foods prefer not to eat. ____________,_____________, _______________.
Foods he/she is Allergic Too: _______________, _________________,__________________.
Infants:
Formula is given how often: Every How many Hours? _________.
How many ounces every feeding? __________ oz(s)
Sleep Habits:
Does the child have his/her own room? YES__ NO___
Does the child sleep alone? YES___ NO___
Toilet Habits:
Can the child manage their clothing at the toilet? YES____ NO____
Can the Child tell you when they need to go to the bathroom? YES____ NO____
******Please initial after reading and agreeing to each statement. ********
I have received a summary of licensing requirements. ______
I do hereby authorize emergency medical care. _______
I have received a copy of the agency policy (Parent’s Handbook). ________
My school-age child’s immunization record is on file at the school attending._________
___________________________________________/________________________________
Signature of Parent(s)
Date
(For Office Use Only - Below)
Date child is withdrawn____________________
Wkly. Fee(s)_______________
Reason for withdrawal___________________________
EMERGENCY INFORMATION
(PLEASE FILL OUT COMPLETELY, WE ALSO NEED PROOF OF SCHEDULES FROM YOUR EMPLOYERS AND/OR
SCHOOLS SHOWING THE HOURS AND DAYS YOU WORK IF YOUR CHILD IS HERE LONGER THAN 8 HOURS.)
* REMEMBER TO FILL OUT NEW FORMS WHEN YOUR INFORMATION CHANGES
CHILD’S NAME (first)__________________(middle)_______________ (last)_______________________
MOTHER’S NAME ____________________________________________________________________
HOME #(____)_____-________ CELLULAR #(____)____-_________ ALT. #(____)_____-_________
NAME OF EMPLOYER______________________________ HOURS YOU WORK _______________
WORK #(____)_____-________ EXT._____________
DAY-TIME PHONE # (That you can be reached at all times throughout the day)
(____)_____-________
NAME OF SCHOOL (If applicable) _______________________________________________________
DAYS & HOURS YOU ATTEND_________________________________________________________
SCHOOL #(____)_____-_________ EXT.____________
FATHER’S NAME _____________________________________________________________________
HOME #(____)_____-________ CELLULAR #(____)____-_________ ALT. #(____)_____-_________
NAME OF EMPLOYER______________________________ HOURS YOU WORK _______________
WORK #(____)_____-________ EXT.________
DAY-TIME PHONE # (That you can be reached at all times throughout the day)
(____)_____-________
NAME OF SCHOOL (If applicable) _______________________________________________________
DAYS & HOURS YOU ATTEND_________________________________________________________
SCHOOL #(____)_____-_________ EXT.____________
EMERGENCY CONTACT NAME (other than yourself or your spouse if possible):
______________________________________________________________________________________
HOME #(____)_____-________ CELLULAR #(____)____-_________ ALT. #(____)_____-_________
PHYSICIAN’S NAME __________________________________________________________________
OFFICE # (____)_____-________
HOSPITAL PREFERENCE:_______________________________________________________________
ANY KNOWN MEDICAL PROBLEM:_____________________________________________________
ALLERGIES IF ANY:___________________________________________________________________
EMERGENCY INFORMATION
(PLEASE FILL OUT COMPLETELY, WE ALSO NEED PROOF OF SCHEDULES FROM YOUR EMPLOYERS AND/OR
SCHOOLS SHOWING THE HOURS AND DAYS YOU WORK IF YOUR CHILD IS HERE LONGER THAN 8 HOURS.)
* REMEMBER TO FILL OUT NEW FORMS WHEN YOUR INFORMATION CHANGES
CHILD’S NAME (first)__________________(middle)_______________ (last)_______________________
MOTHER’S NAME ____________________________________________________________________
HOME #(____)_____-________ CELLULAR #(____)____-_________ ALT. #(____)_____-_________
NAME OF EMPLOYER______________________________ HOURS YOU WORK _______________
WORK #(____)_____-________ EXT._____________
DAY-TIME PHONE # (That you can be reached at all times throughout the day)
(____)_____-________
NAME OF SCHOOL (If applicable) _______________________________________________________
DAYS & HOURS YOU ATTEND_________________________________________________________
SCHOOL #(____)_____-_________ EXT.____________
FATHER’S NAME _____________________________________________________________________
HOME #(____)_____-________ CELLULAR #(____)____-_________ ALT. #(____)_____-_________
NAME OF EMPLOYER______________________________ HOURS YOU WORK _______________
WORK #(____)_____-________ EXT.________
DAY-TIME PHONE # (That you can be reached at all times throughout the day)
(____)_____-________
NAME OF SCHOOL (If applicable) _______________________________________________________
DAYS & HOURS YOU ATTEND_________________________________________________________
SCHOOL #(____)_____-_________ EXT.____________
EMERGENCY CONTACT NAME (other than yourself or your spouse if possible):
______________________________________________________________________________________
HOME #(____)_____-________ CELLULAR #(____)____-_________ ALT. #(____)_____-_________
PHYSICIAN’S NAME __________________________________________________________________
OFFICE # (____)_____-________
HOSPITAL PREFERENCE:_______________________________________________________________
ANY KNOWN MEDICAL PROBLEM:_____________________________________________________
ALLERGIES IF ANY:___________________________________________________________________
PHOTOGRAPH RELEASE FORM: CHILDREN
I hereby grant permission for photographs to be taken of my child’s activities at Gartland Child Development
Center, Inc. for the use of training teachers or the public about early childhood care and education. I
understand that these photos may appear in forms such as display panels or teacher-made books and that I am to
receive no compensation for my child’s appearance. I also understand that my child’s participation confers on
me no ownership rights to the photographs or negatives whatsoever.
Child’s Name--------------------------------------------------------------------------------------------Parents or Guardian_____________________________________________________________
Address______________________________________________________________________
City_____________________________State________________Zip_____________________
Phone_______________________________Cell_____________________________________
Date_________________________________
Signature of Parents or Guardian__________________________________________________
Form HS-19f9
Revised
MaY2011
Tennessee
Department of
Human Services
(TDHS)
Child and ActultCareFood Program(CACFP)
INCOME ELIGIBILITY APPLICATION FOR CHILD CARE CENTER PARTICIPAN
PART 1A - NAME OF CHILD CARE CENTER(Enterthenameof thechildcarecenter):
PARTlB_PARTIclPANT(m(Entertheinformationbelowforallchildrenfromyourhouseholdthatare
enrolledfor careattbechildcarecenter):
Name
Checkif FosterChild
Age
NUTRITION
PART 2A - HOUSEHOLDSWHICH ARE CUNNENTIY RECEIVINCBENEFITS
THESUPPLEMENTAL
TI.IROUGH
ASSISTANCE
(SNAP),OR FAMILIES FIRST(FF)CASHASSISTANCE
OR FAMILIES FIRST(FF) CHILD CARE
PROGRAM
ASSISTANCE(lf yourhouseholdis now receivingbenefitsunderoneor moreof theseprogralns,completethis pargandsip the
OR FF Child
statementin Part 4 - Do not complete Part 28.): ACCENTCaseNo, for SNAPor FF CashAssistance:
CareAssistanceCaseNo.:
PART 28 - ALL OTHERHOUSEHbID MEMBERS(tf no informationis enteredin Part2A above,completethispart for all
householdmembersnot identifiedin Part lB aboveandsip thestrtementin Part4. Attachadditionalsheetsasnggglqgry)from
Received
Payments
Namesof All OtherHousehold
ChildSupport,
Alimonyor
fromWork
Eamings
&
Retirement"
Pensions,
Members
(Before
Otherlncome
SocialSecuritY
Deductions)
I
$
-
PctYear
I
ocr vcar
$
PerYear
2.
$
PcrYgal
$
ocl veat
(
DCt VCAi
3.
$
Per YEat
$
ocr vcar
(
DCr YCA'
4.
$
Pcryca
$
ocr vcar
S
Pcr ycar
iot"l norUci
follons:MultiplyWccklyincomcby 52,Bi-wccklyin*r.irroi"cd
as
calculated
Ycarlyincome.is
Monthly
and
24,
by
nticc
i
month)
26,
Scmi-monUfy
rncom.@G-O
wccks)
by
everytrvo
incorrrc bv 12 Do not round rrn mv nrrmhcn
- Pleasecheckif you do not wantthe informationin thts
FSRT 3 - N{"di""id -d Statechildrd;i Hiilth tnsumnceFrograrns
lnsurance
Programs:- DO NOT WANT AP?LICATION
Aiplicationto be sharedwith the MedicaidandStateChildren's=Health
INFoRMATIoN To BE SHAREDwITH THE MEDICAID AND STATECHILDREN'SHE-ALTHINSURANCEPROGRAMS.
*tton I peXnLrlES FORMISREPRESENTATION:
that
this informationis beinggivenfor thereceiptof Federal
I
understand
I certiff that all of theaboveinformationis trueandcorrect.
of the
andthatthe deliberatemisrepresentation
Fpnds;that institutionofficialsmay verifi the informationon thestatement;
. , .
informationmaysubiectme to prosecutionunderapplicableStateandFederallaws'
(ontylastfour
GfiC'r-;q.Nr.fi
Adult;
of
Signaturc
hintcd Nunc of Adult :
digits):
Sbe€t:
StateandZip Code.
City:
HomcTelcPhone:
F". Eth"tcitfiiease checkoneof the
American
following: - Hispanicor Latino Not Hi"panicoi t-urino.For Race,pleaseiheck oneor more'of the following:-_
White'
Islander
Paeinc
other
lndian or AlaskanNative _ Asian _ alaci or AfricanAmerican- NativeHawaiianor
Dl-^--
---
d.-
,|-G-:r-:^-^
^f
EIL-:^:|,
^-r
D^^^
^-
rlra hanlr ^f thic nnnlicafion
of theenrolledchildrenidentifiedabove,prcas€crsrs;
FOR INSTITUTION USE ONLy: To identifytheeligibiliryctassificarion
Eligibleor lncomeEligible
Free,Reduced-price
or paid. To identifuttreUasisfor cllsifiiation, pleasecircle:Categorically
DeterminingOfficial Simature:
Date:
Gartland Child Development Center, Inc.
POLICY AGREEMENT
1. The approximate hours my child will attend the center will be _______ to _______ .
2. I understand that my child cannot be left at the center more than 9 hours unless I can prove in writing
that I work longer hours. Also if, I only attend school the day care will need a copy of my class
schedule.
3. I agree to pay my parent fee of $_______ in advance each week whether or not my child is in
attendance until he/she is officially withdrawn from the center. I understand that this amount is to be
paid in full each Friday, no later than 9:00 a.m. Monday morning and a late fee of $5.00 will be
charged each day it is not paid in full.
4. I agree that my child will participate in the curriculum program for which he/she is enrolled, this
includes the summer program for my school age child(ren).
5. I agree to pay $5.00 per minute late pick-up fee if my child is not picked up by 5:30 p.m. This fee must
be paid as soon as they are picked up or no later than by the next morning or the child cannot stay or
return until paid in full or arrangements has been approved.
6. I understand that in accordance with the state law the required health records must be submitted to
the center as a prerequisite for any child’s attendance as they are updated.
7. I agree to bring my child into the building each morning (me or my designated person), establish
contact with a staff member, sign the child in and out with my complete signature and accurate time
or (pay a $5.00 fee if not completely filled out), and put the child’s belongings in the child’s designated
location.
8. I agree to submit in writing a (two) 2-week notice before withdrawing my child from the center. I
understand that I will be charged a full week’s rate even if my child is withdrawn prior to the end of
the week.
9. If the center determines your child cannot adjust to the program’s curriculum, the child will be
withdrawn after one weeks notice and this agreement will be terminated.
10. I have received a copy of DHS’s licensing requirements.
11. I understand that this agreement is subject to change with proper notice.
12. I have received a copy of the Parent’s Handbook and read the policies of this Center
and agree to
comply with these policies.
13. I understand that my child cannot be left at the Center for more than 10 hours on a daily basis
without paying additional fees.
14. Any DHS certificate child cannot be absent over five (5) days during a 2-week period without having to
pay the total weekly fee. DHS will not pay any of the weekly parent fees. The only exception is a
written statement of approval from the DHS Certificate Program.
Name of child ______________________________________
Parent’s Signature __________________________________
Director’s Signature _________________________________
Date __________
Date __________