Wallace Memorial After School Care & Camp Wallace Enrollment Application School Year 2015-2016/Summer 2015

Select Programs:

Summer Only____ Summer & School Year_____ School Year Only_____

Select Days:

Full Time____ Part Time (circle 3 days or 2 days) M T W Th F

Child Information:

Child’s Name __________________________________________________________________ (Last) (First) (Middle) (Name Used)

Address & Zip Code _____________________________________________________________

Home Phone_________________________ Church you attend: __________________________

Sex: Male____ Female_____ Age: ________ Date of Birth: ________________________

School your child attends: ________________________________________________________

Grade your child is enrolled in: ____________________________________________________

Are your child’s immunization records on file at school? Yes No

(If your child is not in a Knox County School we need a copy of their shot records.)

Tell us about your child

Brothers (Name & Age) __________________________________________________________

______________________________________________________________________________

Sisters (Name & Age) ____________________________________________________________

______________________________________________________________________________

What are your child’s favorite activities? _____________________________________________

______________________________________________________________________________

Does your child have any fears? ____________________________________________________

______________________________________________________________________________

Can your child swim? ____________ Do they need to wear a life jacket? ___________________

Is there any other information you would like to share with us about your child? ____________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

I have received a copy of the Summary of Licensing Requirements for Child Care Centers as set forth by DHS.

Parent (Gurdian) Signature: _______________________________________________________________

Parent Information

Does your child live with both parents? _____________________________________________

If no, child lives with:____________________________________________________________

If the child is not living with the parent/parents, has the person responsible for the child’s welfare given

certified documentation to the After School office? Yes No

Father’s Information:

Father’s Name_________________________________________ Home Phone: __________________

Address: _________________________________________________ Zip Code: __________________

Cell Phone: ______________________________ Email: _____________________________________

Father’s Employer: ________________________________ Work Phone: _______________________

Address: ________________________________________________ Zip Code: ___________________

Business Hours: ______________________________________________________________________

Mother’s Information:

Mother’s Name________________________________________ Home Phone: __________________

Address: _________________________________________________ Zip Code: __________________

Cell Phone: ______________________________Email:______________________________________

Mother’s Employer: _______________________________ Work Phone: _______________________

Address: ________________________________________________ Zip Code: ___________________

Business Hours: ________________________________________________________________

Emergency Information: Person/Persons, other than the parents, who are authorized to act in case

of emergency, or to pick up my child in my absence.

1. Name: ______________________________________ Home Phone: ____________________

Address: ____________________________________ Cell Phone: ______________________

Employer: __________________________________ Work Phone: _____________________

2. Name: ______________________________________ Home Phone: ____________________

Address: ____________________________________ Cell Phone: ______________________

Employer: __________________________________ Work Phone: _____________________

3. Name: ______________________________________ Home Phone: ____________________

Address: ____________________________________ Cell Phone: ______________________

Employer: __________________________________ Work Phone: _____________________

4. Name: ______________________________________ Home Phone: ____________________

Address: ____________________________________ Cell Phone: ______________________

Employer: __________________________________ Work Phone: _____________________

5. Name: ______________________________________ Home Phone: ____________________

Address: ____________________________________ Cell Phone: ______________________

Employer: __________________________________ Work Phone: _____________________

Child’s Health History

_________________________________ _____________________ ______________________________

Child’s Name Birth Date Parent/Guardian’s Name The answers to these questions will help us to know if your child has any medical problems. We need this information in case he/she

should become ill and we would be unable to reach you right away. Please circle the right answer. We will go over this checklist with

you when you have finished.

Pregnancy and Birth

1) Were there any problems with the pregnancy or your child’s birth? Yes No

2) Was his/her birth weight under 5 ½ pounds? Yes No

3) Did the baby have any problems in the hospital? Yes No

Medical Problems

4) Has your child ever been in the hospital overnight? Yes No

5) Is your child taking any medicine? Yes No

6) Any allergies or reactions to medicine, DPT, or other shots or insects? Yes No

7) Has your child had asthma or wheezing? Yes No

8) Does your child have speech or hearing problems? Yes No

9) Has your child had more than 2 ear infections in a year? Yes No

10) Has your child had tonsillitis? Yes No

11) Does your child have trouble with his/her eyes or seeing? Yes No

12) Has your child had a bladder or kidney infection? Yes No

13) Does he/she have burning when urinating? Yes No

14) Does he/she have seizures, fits, or shaking spells? Yes No

15) Have you been told your child has a heart murmur? Yes No

16) Is your child able to play as hard as other children? Yes No

17) Has your child ever had a bumpy, swollen reaction to the TB skin test? Yes No

18) Has your child ever been with anyone who has TB? Yes No

19) Has your child ever had worms? Yes No

20) Does your child scratch his/her genital area? Yes No

21) Is his/her bottom or genitals red or sore? Yes No

22) Is your child a hemophiliac? Yes No

23) Is your child on a heart monitor? Yes No

24) Does your child have tubes in his/her ears? Yes No

Older Girls

25) How old was your daughter when she had her first period? Yes No

26) Does she have any problems with her periods? Yes No

General Development

27) Is your child in special education classes in school? Yes No

28) Does your child get along with other children? Yes No

29) Is he/she usually happy? Yes No

30) When did your child last see a doctor? ___________________________________

Continued on Next Page

Continued from Previous Page

Is your child taking any medication? Yes No

If yes, please list below. You must sign a Medical Authorization form before we will administer any

medication. Also, please list any side effects which might occur and the appropriate action we are to take.

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

Does your child have any allergies to medicine, insects, food, etc.? Yes No

If yes, lease list below.

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

Does your child have asthma or wheezing? Yes No

Does your child have seizures? Yes No

Does your child have any special problems not indicated above? Yes No

If yes, please explain. ____________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

Medical Wavier

On those occasions when I am unavailable, I ______________________________ authorize the staff of (Parent Name)

Wallace Memorial Baptist Church After School Care & Camp Wallace to obtain emergency medical

assistance for _______________________________________. (Child’s Name)

Local Doctor: _____________________________________ Phone Number:_______________________

Group Name and Address________________________________________________________________

Parent/Guardian Signature: ______________________________________ Date:____________________

WMBC After School Care & Camp Wallace Parent Agreement

I, __________________________________, hereby give my child _______________________________ (Parent Name) (Child Name)

permission to participate in all activities of Wallace After School/Summer Program and do realize this will

include field trips which will be announced at the appropriate time. Field trips may be changed due to

weather or other unforeseen circumstances. I understand I must sign a permission form before my child

may go on field trips.

I have read the After School agreement and policies. I understand the policies, rules and payment schedule

for the program and do hereby agree that my child and I will comply accordingly.

If the Director, Assistant Director, or their designated authority makes the judgment that the person picking

up a child from the center is incapacitated in their ability to remove the child from the center, then the

other parent or an authorized emergency person with permission to pick up your child will be called to make

a decision as to whom will come to the center for your child. We will call the police or proper authorities if

we feel the action is necessary for the protection of the child/children.

I, _____________________________, the parent or legal guardian, realizes that when my child is removed (Parent/Guardian Name)

from the program at my request, with permission from the Director or Assistant Director, Wallace Memorial

After School/Summer Program is released from liability for the child’s safety, health and welfare upon

leaving the building. Liability then becomes the responsibility of the parent and/or guardian who removes

the child from our supervision.

In the event you must contact the staff by phone to advise another person will be picking up your child, we

will take the information and then contact the parent at the phone number listed on the enrollment form to

verify that the parent has, in fact, given permission.

No child may leave the facilities with another parent/child enrolled in the program without written and

dated consent from the parent or legal guardian. The parent/legal guardian must comply with the TCA & 36-

6-105 (A copy of this statute is available in the After School Office) to provide reasonable notice in physical

custody with a certified copy of a valid court order to be provided to the staff.

If any authorized person calls for your child, he/she will be refused permission to leave the facilities with

your child until the parent or authorized person can be contacted to confirm who made the telephone call.

___________________________________________ _____________________________

Parent (Guardian) Signature Date

WMBC After School & Camp Wallace Discipline Policy

Children occasionally do display and will be exposed to aggressive behavior. This may take the form of

biting, hitting, pushing, or kicking. The staff uses various techniques to limit and correct such behavior, but

parents must understand that when children are in a group setting, the exposure to aggressive behavior is

greater than it might be at home. The purpose of discipline is to help children learn acceptable behavior and

develop inner controls. When re-directing or guiding a child’s behavior, the age, intellectual development,

emotional make up, and past experiences will be considered and consistency will be maintained in setting

rules and limits for children. Corporal punishment is not consistent with this objective and is prohibited at

the After School and Camp Wallace.

The following is a list of some alternative forms of discipline that will be used:

*Model appropriate behavior

*Tell the child what he/she can do.

*Establish eye contact with the child when talking to them.

*Give the child choices whenever possible.

*Encourage the child to problem solve and try to work out conflicts.

*Re-direct a child to another activity.

*Physically hold a child until he/she can gain control of themselves.

*Remove the child from the situation.

*Isolate the child from the group.

*Call a parent to come for the child if the child cannot regain control of him/herself.

Limits of Behavior:

*You may not hurt others.

*You may not hurt yourself.

*You may not hurt staff.

*You may not damage After School Equipment.

If a child is having more difficulty than usual with discipline in the classroom, the behaviors displayed by the

child will be discussed with the parents along with specific techniques being used by the staff to help guide

the child to more appropriate behavior. Support from the parents with their discipline at home and of our

discipline in school is expected. All aggressive behaviors that are harmful to other children, teachers, or to

the child him/herself will be documented and signed by the parents. Situations that continue to include

harmful behaviors will be evaluated by the Director in considering the safety and well-being of all children.

The Director will be involved in any final decision to remove the child from the program if the behavior

continues to be harmful to other children and/or staff.

Parents Acknowledgement:

___________________________________________ _________________________

Parent (Guardian) Signature Date

WMBC After School Care & Camp Wallace

ENROLLMENT REGISTRATION AGREEMENT

PLEASE READ EACH SECTION LISTED BELOW, THEN SIGN AND DATE AT THE BOTTOM OF THE FORM.

SECTION 1: TUTION AND FEES

REGISTRATION FEE: I UNDERSTAND THAT AN ANNUAL, NON REFUNDABLE FEE, registration fee of $50 shall

be paid in advance to enroll my child. Annual registration fee will be added to my account upon each year of

anniversary.

PAYMENT OF TUITION: I understand that tuition is due and payable on MONDAY of each week.

LATE OR UNPAID TUITION: A $20 late payment fee will be charge to all accounts not paid by 6:00 p.m.

Friday. Failure to pay will result in your child not being able to attend on Monday or until the account is paid

in full. Every account should have a $0 balance by 6:00 p.m. Friday.

RETURN CHECK POLICY: A return check fee of $30 will be applied to your account for any return check. We

will not continue to receive bad checks; you will need to make arrangements to pay with money order or

cash.

CHARGES AND PROCEDURES FOR LATE PICK UP: Our facilities are open from 6:30 a.m. until 6:00 p.m. in the

summer and on in-service days; 3:00 p.m. until 6:00 p.m. during the school year. We cannot keep children

earlier or later. If your child is late being picked up, there is a $1.00 per minute with a minimum of $5.00

late fee per child. You must make contact with the staff to let us know if you are going to be late. If no

contact has been made from the parent or authorized person on the pickup list, then we are required to

notify DCS (Dept. of Children Services) by 6:30pm. Persons authorized to pick up must have proper I.D. to

pick up child.

WITHDRAWAL FROM PROGRAM: You must give a 2 week notice to withdraw from our program. Your

account must be paid in full on Monday to continue the last week.

TERMINATION BY THE PROGRAM: Wallace After School and Camp Wallace reserves the right to terminate

enrollment of a child due to discipline, parent intoxication, parent misconduct toward staff, and family

divorce/conflict that disturbs the program. I understand that as a parent that I am liable for the acts of the

child while under the care of Wallace After School/Camp Wallace.

PARENT PORTAL: I understand it is my responsibility to sign up for the “Parent Portal” text message

communication system. There is a Parent Portal direction sheet in this packet. I also understand it is my

responsibility to update the Parent Portal if I have new contact information. To sign up, text @CampWall to

81010.

Continued on Next Page

Continued from Previous Page

SECTION 2: VACATION, HOLIDAYS AND ANY CLOSINGS

VACATION: I understand that I will receive 1 week vacation per school year and 1 week vacation per

summer. I understand that my child has to be absent to receive credit for the week. I understand that

during the summer I will pay for the week my child is out for vacation. Then I will receive that last full week

of summer for no charge. My child does not have to be absent the last week to receive that credit.

HOLIDAYS: I understand that the center will be closed on the following holidays: New Year’s Day, Good

Friday, Memorial Day, Independence Day, Labor Day, Thanksgiving (Thursday & Friday) and the week of

Christmas Eve and Christmas. I understand that no reduction in fees will be allowed.

INCLEMENT WEATHER OR OTHER DISASTERS: I understand that it is After School/Camp Wallace Program’s

intention to be open and provide child care service. But inclement weather, natural disaster, or major

building issue may disrupt service from time to time. Be sure to contact us to ensure we are open or if there

are delays or early closings. All closing information will be sent by text message. I understand that no

reduction in fees will be allowed.

SECTION 3: DAILY PROCEDURES

DAILY SIGN-OUT: You must sign in and sign out your child every day. I understand that I am required to

enter the facilities with my child and I must escort my child to their designated area each day.

ILLNESS: I understand that I will be notified should my child become ill during the day, and will pick up my

child promptly or make arrangement for authorized emergency contact person to pick up. If my child is

exposed to a contagious disease, I agree to notify the staff and I understand that my child will be re-

admitted according to the re-admission criteria in the Policy Handbook. I understand that Wallace is not

liable for accidents or illness occurring while in our care unless it can be proven that the accident was the

direct result of staff negligence.

INTERVIEWING CHLDREN AND INSPECTING RECORDS: I understand that the State of Tennessee (DCS, DHS)

has the right to enforce and the administration agency has the authority to interview children or staff, to

inspect and audit child and facility records and to observe the physical condition of the children in the

program without consent of parent or Wallace Memorial staff.

I have read the above policies and agree and understand the terms of Wallace Memorial Baptist Church

After School Care & Camp Wallace policies. We must have signature on file, as part of the enrollment policy.

Parent/Guardian Signature: _________________________________ Date ______________________

Director Signature: ________________________________________ Date ______________________

Camp Wallace Permission Form

My child has my permission to:

*Please initial next to each one that applies to your child*

_____ Have their picture taken by After School Staff

_____ Have their picture posted at the center or used on a

DVD to be given to Camp families

_____ Have their picture in promotional material for the center

_____ Have their picture posted on Facebook

_____ Have Sun Screen provided by the After School applied

by the After School Staff

_____ Have Sun Screen provided by the Parent applied by the

After School Staff

_____ Ride Fire Tower Falls at Splash Country (3rd-7

th grades)

_____ Have “Neosporin” type ointment applied if necessary

Child’s Name: ______________________________________________

Parent/Guardian Signature: _________________________________

Date: ____________________

Summer T-Shirt Order Form

Name: ______________________________

SIZE (Children) Quantity $$$ Due

Small

Medium

Large

X-Large

Shirts are $6.00 each

SIZE (Adult) Quantity $$$ Due

Small

Medium

Large

X-Large

Amount Due: ___________

Amount Paid: ___________

After School Care & Camp Wallace

Parent Security System Rules

Each family will receive one security card and an access code. This card will let you into the center

during operational hours only.

This card will only activate the doors to the After School/Camp Wallace facility. Please remember

the more people who have your card, the less secure our system becomes.

Please remember to use your card every day.

Should you lose your card there will be a $5.00 replacement fee.

If you withdraw from the program, your card will be deactivated and it will need to be returned to

the center.

I HAVE REICEIVED MY SECURITY CARD AND READ THE ABOVE INFORMATION AND UNDERSTAND

THE POLICY.

___________________________________________

Parent (Guardian) Signature

Wallace Memorial After School & Camp Wallace Payment Policy

Fees are due Monday of each week for that week. A $20.00 late payment charge will be added to

all accounts not paid by 6:00 pm Friday. Failure to pay the following Monday will result in your

child not being able to attend that Tuesday.

I understand and accept this payment policy:

_________________________________________ ____________________

Parent (Guardian) Signature Date

On-Site Visit Verification Form

I, ______________________________, parent/guardian of________________________________,

have visited the facility prior to my child being enrolled.

*I have also received a copy of the handbook regarding the facilities’ policies and licensing rules

enforced by the Department of Human Services.

*I have been informed of the practices of the After School/Camp Wallace program as to their

schedule for snacks, play time, etc.

*I understand that I must give a 2 week notice before I can drop my child from the After

School/Camp Wallace Program. I also understand that if I do not give this notice I will be charged

for 2 weeks. I understand that I must pay the balance for the last week by the Friday prior to their

drop date, to attend the last week.

*I understand that it is my responsibility to contact the After School staff when my child will not be

riding the bus. I understand that I will be charged if I fail to call.

_________________________________________________ __________________

Parent (Guardian) Signature Date