ENROLLMENT FORM
5207 W. 26th Ave.
Edgewater, CO 80214
P: (303) 237-6356
F: (303) 237-6370
Tinyheartsacademy1@gmail.com
Omar Suner: omar@tinyheartsacademy.com
Christy Hersh: christy@tinyheartsacademy.com
Child’s Information: Last Name:_______________________ First Name:____________________________
Male: _____ Female:_____ DOB:____________________ Enrollment/start date:________________
Address:__________________________________________________________________________________
City/State___________________________________________ Zip_____________________
Home Phone:___________________
Father’s Name: ____________________________________________________________________________
Employer: __________________________ Business Address:_______________________________________
City/State___________________________________________ Zip_____________________
Work Phone:___________________ Cell:_____________________ e-mail: ____________________________
Hrs of work:__________________ In case of emergency first preference to be contacted at: Work___ Cell____
Mother’s Name: ___________________________________________________________________________
Employer: ___________________________ Business Address: _____________________________________
City/State___________________________________________ Zip_____________________
Work Phone:___________________ Cell:_____________________ e-mail: ____________________________
Hrs of work:__________________ In case of emergency first preference to be contacted at: Work___ Cell____
Other authorized persons to pick up:
Name: ____________________________________________________________________________________
Phone: ____________________________________________ Relationship: ___________________________
Address: _____________________________________________________________________________
City/State _______________________________________________Zip_______________________
Name: ____________________________________________________________________________________
Phone: ___________________________________________ Relationship: ___________________________
Address: _____________________________________________________________________________
City/State _______________________________________________Zip_______________________
Name: ____________________________________________________________________________________
Phone: ___________________________________________ Relationship: ___________________________
Address: _____________________________________________________________________________
City/State _______________________________________________Zip_______________________
Additional persons to contact in the event of an emergency:
Name: ____________________________________________________________________________________
Phone: ________________________________ Relationship: ____________________________
Address: ____________________________________City/State _________________________Zip__________
Name: ____________________________________________________________________________________
Phone: ________________________________ Relationship: ____________________________
Address: ____________________________________City/State _________________________Zip__________
Name: ____________________________________________________________________________________
Phone: ________________________________ Relationship: ____________________________
Address: ____________________________________City/State _________________________Zip__________
Parent/Guardian Signature: ___________________________________ Date: ___________________________
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I/We do herby authorize Tiny Hearts Academy to act as agents for the undersigned:
to consent to any medical or surgical diagnosis or treatment or hospital care deemed
advisable by or administered by a licensed physician, in the event such help of an
emergency medical nature becomes necessary.
Physician’s Name: ________________________________________________________
Address: ________________________________________________________________
Phone: ___________________________________
Remarks (Allergies):_______________________________________________________
Dentist’s Name: __________________________________________________________
Address: ________________________________________________________________
Phone: ___________________________________
Hospital:
____ Lutheran Medical Center
8300 W 38th Ave
Wheat Ridge Co 80033
(303) 425-4500
OR
____ St Anthony’s Hospital
11600 W 2nd Pl
Lakewood Co 80228
(720) 321-0000
OR
____ Children’s Hospital
13123 East 16th Ave
Aurora Co 80045
(720) 777-1234
OR
Other: ________________________________________________________________
Address: ______________________________________________________________
Phone: ___________________________________
Parent/Guardian Signature:__________________________________________________
Date: ________________________
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Statement of Authorization
Please initial after each statement and sign at the bottom.
! I hereby grant permission for my child to be included in developmental evaluations
and observations by any licensed therapists deemed necessary. _____________
! I hereby grant permission for photos to be taken of my child in association with the
center programs and possibly used for publicity without financial
compensation.________
! I hereby grant permission for my child to be given prescription medication with a
doctor’s authorization note and “Parent Permission Form” in its original container
without liability to administering staff._______
! I hereby grant permission for the director or acting director whatever steps that maybe
necessary to obtain emergency medical care if warranted. These steps may include,
but not limited to the following:
1. Attempt to contact a parent, guardian or other emergency contacts.
2. Attempt to contact the child’s physician.
3. If we cannot contact you or the child’s physician, then we will do any of the
following:
a. Call another physician or paramedics.
b. Have a child taken to an emergency/ hospital in the company of a staff
member.
4. Any expenses incurred in #3 above, will be the ultimate responsibility of
child’s family.______
! I hereby acknowledge that I have received and read the policies and procedures for
the parents._____
! I hereby acknowledge that the center will not be responsible for anything that may
happen as a result of false information given at time of enrollment or there after.____
! I hereby acknowledge that the center will not be responsible for any child who has
not been signed in upon arrival for the day._______
Child’s name:____________________________________________________________
Print Parent/ Guardian Name:________________________________________________
Signature:_________________________________________________ Date:_________
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Absence/ Illness
This policy applies to illness only. Sick children will be sent home, this includes but is
not limited too, a temperature of 100 degrees or more, vomiting, diarrhea, discharge from
eyes and/or ears or unknown rashes. Any child with a fever must be fever free without
medication for 24 hours before returning. If the illness persists more than two days a
note from physician is required before child can return.
Withdrawal from Tiny Hearts
A two week notice of intention to withdraw from Tiny Hearts must be given to the center
in writing. Tuition will not be refunded unless two weeks prior notice is given.
Loss or damage of children’s articles
We are not responsible for any loss or damage to children’s articles. Children learn
through play and many times this means getting dirty. For your protection please label
all of your child’s articles.
Each child is accepted to Tiny Hearts on his/ her own merit regardless of race, color, or
religion. The director or any other staff member shall report to Social Services, as
required by law to report any suspicion of child abuse, sexual abuse or otherwise, neglect
or endangerment for which they become aware. I give permission for Tiny Hearts to use
in any literature any photo in which my child may appear. Tiny Hearts holds the right, at
its discretion to dismiss any customer or child whose activities are deemed detrimental to
other children in the center itself.
I have read and agree to the terms listed above:
Child’s Name:_____________________________________________
Parent Name: ________________________________________________ (Please Print)
Signature:_________________________________________________ Date:_________
Director’s Signature:_________________________________________ Date:_________
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Transportation Agreement
Child’s Name:____________________________________________________________
School Name:____________________________________________________________
School Address:__________________________________________________________
School Phone #:________________________________
I. Transportation in Tiny Hearts vehicle
A. Tiny Hearts responsibilities
1. Tiny Hearts will drop off your child at school
Drop off time:___________________ Pick up time:_________________
Special instructions: __________________________________________
2. Tiny Hearts Academy is not responsible for picking up or dropping off
children
at any other times other than times mentioned above. Parents must
make prior arrangements themselves.
3. Tiny Hearts Academy must be notified for changes in non pick up
from school at least 30 minutes prior to pick up time, if not then a $15
fee will be charged.
4. Your child will be the responsibility of Tiny Hearts Academy en route
to and from school.
B. Parent responsibilities
1. Parent is responsible for calling the center if your child is dropped off
at school and needs to be picked up by the center.
2. Make sure that the school is aware of and has a designated drop off
and pick up area.
3. Make sure you tell your child where they will be picked up.
Print Child Name:________________________________________________
Parent/ Guardian Signature:________________________________ Date: ____________
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Sunscreen Permission
Here at Tiny Hearts Academy we spend a lot of time outdoors. Young skin in
very sensitive to the sunlight, so we suggest that you send a bottle of sunscreen with your
child’s name on the bottle for their teacher. Please take a moment to fill out this
permission slip and return it. Please note we will not administer sunscreen without your
signed permission.
I give permission for Tiny Hearts staff to administer sunscreen onto my child.
Child’s name:____________________________________________________________
Print Parent/ Guardian Name:________________________________________________
Signature:_________________________________________________ Date:_________
Diaper Cream/Ointment
(infants and toddlers only)
I give permission for Tiny Hearts staff to apply
diaper cream/ointment (that I supply) onto my child.
Child’s name:____________________________________________________________
Print Parent/ Guardian Name:________________________________________________
Signature:_________________________________________________ Date:_________
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Field Trip Information
I give permission for my child to participate in fieldtrips or excursions, whether
walking or riding. I understand that prior notification will be give before the trip
and additional permission forms may need to be signed.
Child’s name:____________________________________________________________
Print Parent/ Guardian Name:________________________________________________
Signature:_________________________________________________ Date:_________
I hear by grant permission for the director or acting director to take
whatever steps necessary to obtain emergency medical care for my child during
fieldtrips.
Child’s Name:____________________________________________________________
M.D. or Clinic Name:______________________________________________________
Doctor’s Name:___________________________________________________________
Doctor’s Address:_________________________________________________________
City:________________________ State:____________ Zip:_________
Doctor’s Phone:_______________________________
Office Hours:_________________________________
Print Parent/ Guardian Name:________________________________________________
Signature:_________________________________________________ Date:_________
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TUITION PAYMENTS
OPEN 6:30AM UNTIL 6:00PM MON-FRI
Age Group
5 days
3 days
(M/W/F)
Infants (6wks-18 mon)
$325.00
$255.00
$185.00
$90.00
Toddlers (18mon -3.5 yrs)
$250.00
$195.00
$140.00
$75.00
Pre-School (3.5yrs - 5.5yrs)
$210.00
$165.00
$120.00
$65.00
2 days (T/Th)
Drop In
Rate
Full Time (5 days/week) based on payment for 4 days with the 5th day free
Part Time spots: Limited Availabilty
**ALL TUITION RATES ARE SUBJECT TO CHANGE**
Annual Registration Fee- $100
Tuition:
*All tuition is paid prior to care given.
*$25 late fee will be assessed to the account each week payment is late.
*5% discount for the oldest child in the same family
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REGISTRATION & SUPPLY FEE
Registration fee is due at time of initial registration and each July thereafter.
Registration fee and supply fee’s are non-refundable.
TUITION
All tuition is paid weekly, bi-weekly, or monthly and is due BEFORE care is given.
$25 late fee is added each week the payment is late.
5% discount for the second child of the family.
Please make all payments by: Cash, Check, Credit Card or Money Order.
I agree that any payment not paid within 10 working days of the due date will result in the
voiding of the contract and a loss in my child’s spot at Tiny Hearts. ______ (Please Initial)
All parental fees are due by the 1st of each month (CCAP Co-pay), $25 late fee is added each week the
payment is late
RETURNED CHECKS
There is a $45 charge for returned checks.
The amount of the returned check and service fee must be paid by Cash, Credit Card or Money Order
only.
If the checks are returned twice then all future payments MUST be paid by Cash or Credit Card only.
PICK UP & DROP OFF
Children picked up after 6:00pm will be charge $1 per minute. NO DROP OFF AFTER 9.30AM
without prior approval.
(Initial)
Late pickup fee must be paid at the time of pickup in Cash.
Center should be notified for changes in pickup from school at least 30 minutes prior to pickup, IF
NOT then a $15 service fee will be charged.
CENTER HOLIDAYS
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Regular tuition is due for holidays when Tiny Hearts is closed.
There are no make up days.
The center will be closed on: Memorial Day, Independence Day, Labor Day, Thanksgiving & the day
after Thanksgiving, Christmas Day and New Years Day.
ABSENCE & ILLNESS
There is no credit for absent days. No attendance for 3 consecutive days without a Doctor’s note
and/or payment for that week will result in a loss in my child’s spot at Tiny Hearts Academy.
(Initials)
Vacation credit: One week’s (5 consecutive days) vacation will be granted to all family’s who
have been enrolled for at least one year. All tuition payments must be current in order to receive
credit.
(Initials)
Sick children will be sent home.
Any child with a fever must have a normal temperature for 24 hours before returning to the center.
All children must have a signed physician’s record on file.
Parents are required to provide current address and phones number(s) at all times.
WITHDRAWAL FROM TINY HEARTS
A 2 week notice of intention to withdraw from Tiny Hearts must be given in writing.
Tuition will not be refunded unless 2 weeks notice is given in writing.
Tiny Hearts reserves the right, at its sole discretion, to dismiss any customer/ child whose activities are
deemed detrimental to other children, staff or the center.
Abuse Reporting/Anti-Discrimination
The director or any other staff member shall report to Social Services as required by the law to report
any neglect; suspicion of child abuse, sexual or otherwise; or endangerment for which they become
aware.
Each child is accepted on his or her own merit regardless of race, color or religion.
We are not responsible for lost articles. For your protection label all of your child’s articles.
Name of Child:__________________________________
Name of Parent/Guardian:______________________________
Parent/Guardian Signature: ________________________________________
Date: ___________________
Surveillance Camera Release
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I,
, have read and understand that Tiny Hearts
Academy utilizes 16 surveillance cameras covering each classroom, entrance and
playground to provide the upmost safety and security for the children.
Viewing
Viewing of surveillance camera footage (either live video feed or recordings) will be
conducted by authorized personnel only. All designated individuals viewing live feed
and/or reviewing recorded video footage will be required to sign a confidentiality
agreement to prevent unauthorized disclosure. Footage is monitored onsite as well as
recorded on a secure DVR.
Access and Release
The owners and director will have access to all real-time and recorded images resulting
from video surveillance employment. Only these authorized employees of Tiny Hearts
Academy may review surveillance camera recorded data. Other individuals who may
have a legitimate need to view recorded video data may be permitted to do so, but only
with the prior approval of the owner of Tiny Hearts Academy. Circumstances that may
warrant a review should be limited to instances where an incident has been
reported/observed or for investigation of a potential crime. A request to review recorded
footage must be submitted in writing, utilizing the Tiny Hearts Academy Surveillance
Footage Request Form. All viewing will be recorded on a log, identifying the need to
review the recording, the individuals present, and the date. The log will be maintained
for a period of 12 months and is located within the office of Tiny Hearts Academy.
Due to HIPPA privacy laws, requests to view footage may be denied. If so, an authorized
employee will review the incident and provide a report to the requester.
Storage and Retention
Recorded surveillance camera data will be retained for a minimum of 30 days (could be
longer as DVR storage capacity increases) unless required for a continuing investigation
of an incident, after which the recorded data will be erased and destroyed. All recorded
data will be stored on assigned secure network video recorders with secured access.
Recorded data retained for investigation purposes will be strictly managed with limited
access.
Parent/Guardian Signature
Date
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Parent and Handbook Policies and Procedures
Available for review online at www.tinyheartsacademy.com
I,
, have read, understand and agree to abide by the
Parent Handbook of Policies and Procedures.
Parent/Guardian Signature
Date
Director/ Staff Signature
Date
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New Child Information Form
Child’s name:___________________________ Date of birth:______________ Sex:____
Nickname(s) child responds to:______________________________________________
1. Reason for choosing childcare for your child:
_________________________________________________________________
2. Family relationships: Who are the primary care givers of the child?
__________________________________________________________________
__________________________________________________________________
Brothers and sisters:
Name
Age
Living with the child?
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Others living in the home:
Relationship to child?
_____________________________________________________________________
_____________________________________________________________________
3. Communication:
What is the main language spoken at home? ______________________________
How does your child communicate his or her needs?
__________________________________________________________________
4. Diapering and toileting:
What is your child’s diapering or toileting routine?
__________________________________________________________________
If your child is using the toilet, please describe how you know when s/he needs to
use it, and what assistance you usually provide:
__________________________________________________________________
__________________________________________________________________
5. Eating:
Does your child have any dietary restrictions or food allergies?
__________________________________________________________________
What are your child’s favorite foods?
__________________________________________________________________
Does s/he have any strong food dislikes?
__________________________________________________________________
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6. Sleeping:
How does your child nap at home?
__________________________________________________________________
How does your child show that s/he is tired?
__________________________________________________________________
Does your child have a special routine before going to sleep?
__________________________________________________________________
Does your child have a special object that s/he sleeps with or uses for comfort?
__________________________________________________________________
7. Developmental:
How does your child like to be comforted?
__________________________________________________________________
How does your child usually react to being separated from the people who will be
dropping him/her off?
__________________________________________________________________
Are there things that your child is afraid of (i.e. dogs, loud noises)?
__________________________________________________________________
How does s/he express anger or react to frustration?
__________________________________________________________________
What do you do when your child does something you think is wrong or bad for
your child, or when your child doesn’t listen to you?
__________________________________________________________________
Do any of your child’s behaviors cause you concern?
__________________________________________________________________
What are your child’s interests? What do they enjoy doing?
__________________________________________________________________
In a few sentences how would you describe your child?
__________________________________________________________________
Are there any holidays or special occasions that you like to celebrate with your
child? Are there any holidays you do not want your child to celebrate?
__________________________________________________________________
Is there any other information that we should know to better serve you or your
child?
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
Name of Parent/Guardian:______________________________
Parent/Guardian Signature: ______________________________________ Date: ___________________
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