Child Enrollment and Health Information for Child Care

Child Enrollment & Health Information

Please complete the form below. Questions? Call us at (440) 899-7911 or email info@westshoremontessori.org.

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Child Enrollment and Health Information for Child Care

This form shall be completed prior to the child's first day of attendance and updated annually and as needed.

Child’s Name(Required)

First Last

Parent Email Address(Required)

Upload JFS1234 here(Required)

Step1: Click here to download the JFS1234

Step 2: Once the form is filled out, please upload it through the file upload option below.

Drop files here or

Max. file size: 8 MB.

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Date of Birth

MM slash DD slash YYYY

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First Day at Program/Home

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Home Address

Street Address City State / Province / Region ZIP / Postal Code

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Home Telephone Number

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Parent/Guardian Name #1

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Relationship to Child

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Home Address

Same as Child's

Street Address City State / Province / Region ZIP / Postal Code

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Home Telephone

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Cell Phone

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Parent's Work/School Name

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Parent's Work/School Telephone Number

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Parent's Work/School Address

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Please indicate if this name should be released if a parent/guardian, of a child attending the program/home requests contact information for other parents/guardians.

Yes

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If you answered yes, please indicate which information above to include on the list

Work #

Cell#

Home#

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Where can you be reached while your child is in this program /home?

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Parent/Guardian Name #2

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Relationship to Child

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Home Address

Same as Child's

Street Address City State / Province / Region ZIP / Postal Code

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Home Telephone

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Email Address

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Cell Phone

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Parent's Work/School Name

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Parent's Work/School Telephone Number

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Parent's Work/School Address

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Please indicate if this name should be released if a parent/guardian, of a child attending the program/home requests contact information for other parents/guardians.

Yes

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If you answered yes, please indicate which information above to include on the list

Work #

Cell#

Home#

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Where can you be reached while your child is in this program /home?

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Emergency Contacts:

Parents cannot be listed as emergency contacts. List the name of at least one person who can be contacted in the event of an emergency or illness if you cannot be reached. Any person listed should be able to assist in contacting you. At least one person listed must be able to take responsibility for the child in case the parent/guardian cannot be contacted and should be at least 18 years of age.

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Contact #1 Name

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Relationship to Child

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Telephone Number

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Address

City State / Province / Region

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Other numbers where emergency contact can be reached (if applicable)

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Contact #2 Name

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Relationship to Child

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Telephone Number

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Address

City State / Province / Region

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Other numbers where emergency contact can be reached (if applicable)

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Name of Physician or Clinic/Hospital

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Address

Street Address City State / Province / Region

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Telephone Number

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Allergies, Special Health or Medical Conditions, and Medical Foods

Fill in this section accurately and completely. Please note that if your child has a current health or medical condition requiring child care staff to perform child specific care, such as: to monitor the condition, provide treatment, care, or to give medication, the JFS 01236 "Child Medical/Physical Care Plan for Child Care" must be completed and be kept on file at the program/home.

You can find JFS 01236 form on the webiste admissions tab

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Child’s Name

First Last

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Does your child have any food, medication or environmental allergies?

Yes

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check all that apply

Food

Medication

Environmental

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Please list and explain

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Does your child’s allergy/allergies require child care staff to monitor your child for symptoms to take action if a reaction occurs, or give em ergency m edication to your child?

Yes - a JFS 01236 "Child Medical/Physical Care Plan for Child Care" must be completed.

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Does your child have a developmental delay or special health or medical condition?

Yes

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please explain

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Does the special health or medical condition require child care staff to perform a procedure, or perform child specific care such as: to monitor your child for symptoms or administer medication during child care hours?

Yes - a JFS 01236 "Child Medical/Physical Care Plan for Child Care" must be completed.

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Does your child have any dietary restrictions, including those for medical, religious or cultural reasons?

Yes

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please explain

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Does this dietary restriction require a modified diet that eliminates all types of fluid milk or an entire food group?

Yes - written instructions from the child's health care provider must be on file.

N/A - program does not provide meals or snacks to the child.

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List any history of hospitalization, outpatient surgery, or previous health concerns that would be needed to assist the staff or medical personnel in an emergency situation.

If not applicable, please type N/A

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List any additional information about your child that would be useful for staff to know, such as eating or sleeping habits.

If not applicable, please type N/A

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List any additional information about your child that would be useful for staff to know, such as special routines, or behavior needs.

If not applicable, please type N/A

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Diapering Statement

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Is your child toilet trained?

Yes (If yes, skip to Emergency Transportation Authorization section)

No (If no, fill out the following:)

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The program's policy is to check diapers every 2 hours. Please indicate if you want your child's diaper checked according to the program's policy or another:

I agree with the program 's schedule

I do not agree

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please check m y child's diaper every hours.

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Emergency Transportation Authorization

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Emergency Transportation Authorization

I give Permission to Transport, Westshore Montessori School has permission to secure emergency transportation for my child in the event of an illness or injury which requires emergency treatment. The emergency transportation service will determine the facility to which my child will be transported.

I do not give Permission to Transport, Westshore Montessori School does not have permission to secure emergency transportation for my child in the event of an illness or injury which requires emergency treatment.

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I wish for the following action to be taken:

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Parent's Signature

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Date

MM slash DD slash YYYY

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Acknowledgement of Policies and Procedures

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I have reviewed and received a copy of the program's or home's policies and procedures/handbook.

Yes

MEDIA RELEASE

Dear Parents:

We frequently take photographs of students to promote Westshore Montessori School. Some of these photos may be used in promotional pamphlets and displays, newspaper advertisements, and on the school website, among other places.

On occasion, print and television media also come to the school to cover events. Your child’s name and image may appear in newspapers and on television if he or she is participating in one of these events.

Please sign form indicating whether or not you provide permission for your child’s image to appear in the media or in any school publications.

Thank you.

Student Name

Media Release(Required)

My child HAS my permission to be photographed by school staff, parents, or the media as part of any promotion of Westshore Montessori School.

My child DOES NOT HAVE my permission to be photographed by school staff, parents, or the media as part of any promotion of Westshore Montessori School.

Parent's Signature(Required)

Date(Required)

MM slash DD slash YYYY

Authorization to Release

If you wish to have your child released by Westshore Montessori School to a person other than the parent, you must provide Westshore Montessori School with the necessary authorization by providing the following information:

Child’s Name(Required)

Directress’ Name

ONLY PARENTS ARE AUTHORIZED TO PICK UP THE ABOVE NAMED STUDENT(Required)

Yes

Name of person authorized

Relationship to child

Cell phone

Home phone

Days of the week

Brief description of the car/license no

Car pool:

Yes

Name of person authorized

Relationship to child

Cell phone

Home phone

Days of the week

Brief description of the car/license no

Car pool:

Yes

If the above is a regular car pool, please state names of other children riding in the car:

Child’s name

Classroom

What other information should we know about the above-authorized persons or those person’s relationship to your child?

What information should WMS know regarding unauthorized persons who may request release, such as a non-custodial parent?

Custodial Parent Signature

Date

MM slash DD slash YYYY

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TUITION POLICY

You have paid a non-refundable tuition deposit of $300, which reserves a place for your child at Westshore Montessori School. Our expectation is that your child will remain enrolled for the entire school year.

If you choose to withdraw your child from school at any time during the first semester (the first semester is defined as July 1st through December 20th), you are responsible for paying the full first semester’s tuition, plus 50% of the second semester’s tuition (the annual tuition will be prorated on a weekly basis).

If a child is withdrawn from school at any time during the second semester, you are responsible for the full amount of the annual tuition and no tuition will be refunded.

Re-location Exception

If withdrawal during the first semester is necessary due to relocation from the Northeast Ohio area, you are responsible for paying the full first semester’s tuition, plus 25% of the second semester’s tuition (the annual tuition will be prorated on a weekly basis).

If a child is withdrawn from school at any time during the second semester, you are responsible for the full amount of the annual tuition and no tuition will be refunded.

Withdrawal at Schools Request

If a child is withdrawn from the school at the school’s request, you are responsible only for the amount of tuition (prorated on a weekly basis) for the time the child was enrolled.

Westshore Montessori Association admits students of any race, religion, and national or ethnic origin.

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Please sign below indicating that you have received, read, and accept the tuition policy.

Signature

Date

MM slash DD slash YYYY