SAMPLE CHILDREN'S ENROLLMENT FORM Page 1of3

1 SAMPLECHILDREN'SENROLLMENTFORMPage1 of3 EntranceDateWithdrawalDate-------------- --------------------------------Child'sN ameSex_AgeDateofbirth_HomeAddress(Street )_CityStateZip_HomePhoneNumber_Father'sN ameHomePhoneNumber_Father'sHomeAddress(i f differentfromchild's) 'sPlaceof EmploymentWorkPhone_Employer' 'sNameHomePhoneNumber_Mother'sHomeAddres s(if differentfromchild's) 'sPlaceof #_Employer' 'sLivingArrangements:(checkone)() BothParents() Mother() Father() OtherChild'sLegalGuardian(s):(checkone)( ) BothParents() Mother() Father() OtherThe childmaybe releasedto the person(s)signingthis agreementor to the following:*NameAddress(Street-City-State -Zip)TelephoneNumber~Relationshipto child'----_Relationshipto Parent(s)or Guardian_Otheridentifyinginformation(if any)_*NameAddress(Street-City-State-Zip) TelephoneNumberRelationshipto child_Relationshipto Parent(s)or Guardian_Otheridentifyinginformation(if any)_PAGE2 of3 Personsto contactin the caseof emergencywhenparentor guardiancannotbe reached:NameTelephoneNumber_NameTelephon eNumber_NameTelephoneNumber_Nameof Publicor PrivateSchoolchildattends,if any.

2 _Child'sdoctoror clinicname------------------------------ -Doctor/clinicphone#_My childhas the followingspecialneeds_The followingspecialaccommodation(s)maybe requiredto mosteffectivelymeetmy child'sneedswhileatthe center:--------------------------------- ----My childis currentlyon medication(s)prescribedfor long-termcontinuoususe and/orhas the followingpre-existingillness,allergies,o r healthconcerns:_EMERGENCYMEDICALAUTHORIZ ATIONS hould(child'sname)Dateofbirth_sufferan injuryor illnesswhilein the careof (Facilityname)_and the facilityis unableto contactme (us) immediately,it shallbe authorizedto securesuchmedicalattentionand carefor the childas maybe \'Ne)shallassumeresponsibilityfor paymentfor ~Guardian:_SignatureDate:_FacilityAdmini strator/Person-ln-Charge_SignatureDate:_ PAGE3 of3 ParentalAgreementswithChildCareFacility( Month)My childwillparticipatein the followingmealplan(circleapplicablemealsa nd snacks).

3 BreakfastMorningSnackLunchAfternoonSnack EveningSnackDinnerBedtimeSnackBeforeany medicationis dispensedto my child,I willprovidea writtenauthorization,whichincludes:date; nameofchild;nameof medication;prescriptionnumber;if any;dosages;dateand timeof day medicationis to be be in the originalcontainerwithmy child'snamemarkedon childwill not be allowedto enteror leavethe facilitywithoutbeingescortedby the parent(s),personauthorizedbyparent(s), or acknowledgeit is my responsibilityto keepmy child'srecordscurrentto reflectany significantchangesas theyoccur, ,telephonenumbers,worklocation,emergency contacts,child'sphysician,child'shealths tatus,infantfeedingplansand immunizationrecords, facilityagreesto keepme informedof any incidents,includingillnesses,injuries,ad versereactionsto medications,etc.

4 ,whichincludemy obtainwrittenauthorizationfromme beforemy childparticipatesinroutinetransportation ,fieldtrips,specialactivitiesawayfromthe facility,and water-relatedactivitiesoccurringin waterthat is morethantwo (2) feet deep.] authorizethe childcarefacilityto obtainemergencymedicalcarefor my childwhen1am not havereceiveda copyand agreeto abideby the policiesand proceduresfor(Nameof Facility)I understandthat the facilitywilladviseme of my child'sprogressand issuesrelatingto my child'scareas wellas anyindividualpracticesconcerningmy child' alsounderstandthat my participationis encouragedin :Date:_(Parent/Guardian)Signed:Date:_(Fa cilityAdministrator/Person-In-Charge)Sam pleTransportationAgreementThisis to certifythat I give_Nameof FacilityPermissionto transportmy child_Nameof Childfromat(am/pm)PickupLocationtoat(am/ pm).

5 DeliveryLocationMy childwill be transportedfromat(am/pm)toat(amJpm)Deliv eryLocationon the followingdays:_____Monday_____Tuesday___ __Wednesday_____Thursday_____Fridayis authorizedto receivemy the eventthe authorized------------Nameof AuthorizedPersonpersonis not presentto receivemy child,the followingproceduresare to be followed:Theis approximatelymilesfromthe the eventthat my childis not to be transportedas outlinedabove,I agreeto notifytheFacilitySignature(Parent/Guardi an)Date_--------------------------Vehicl eEmergencyMedicalInformationChild'sNameD ateof Birth----------------------------------- -------------Address-------------------- ---------------------------------------- ---Father'sName------------------------- ----------------------------------HomePh oneWorkPhone------------------~--------- ---------------------Mother'sName------- ---------------------------------------- -----------HomePhoneWorkPhone----------- ---------------------------------------P ersonto notifyin an emergencyand parentscannotbe reached.

6 NamePhone------------------------------- -----------------------------Child'sDoct orPhone--------------------------------- --------------------Medicalfacilitythe centeruses_Address---------------------- ---------------------------------------- -Child'sAllergies_Currentprescribedmedic ation_Child'sspecialneedsand conditions_In the eventof an emergencyinvolvingmy child,and if_Nameof Facilitycannotget in touchwithme, I herebyauthorizeany furtheragreeto be fullyresponsiblefor all medicalexpensesincurredduringthe treatmentof 'sName---------------------------------- -------------------------Signature(Paren t/Guardian) NutritionEducationProgramFor Women,Infantsand ChildrenWHOISELIGIBLE?

7 >- A pregnantwoman' A breastfeedingwoman>- A womanwhohasrecentlybeenpregnant>- Aninfantora childlessthan5 yearsoldTOBEELIGIBLE,YOUMUSTALSO:>- Havea lowormoderateincomeAND>- Havea of2 SERVICESPROVIDED:>- Nutritiousfoods>- Nutritioncounseling>- Breastfeedingsupport>- HealthcarereferralAPPROVEDWICFOODS:>- Milk,cheese,eggs,cereals,peanutbutter,fr uitorvegetablejuices,drybeansorpeas, :GeorgiaDepartmentofEarlyCareandLearning ChildAdultCareFoodProgramIncomeEligibili tyStatementPARTI:Child(ren)orAdultenroll edtoreceivedaycare-Name:(Last,FirstandMi ddleInitial)FoodStamp,TANF,orFDPIR casenumber,AssistantHeadStartFosterUnit( AU), , is :$lOO/monthly,$lOO/twicea month,$lOO/everyotherweek,$lOO/weeklyc.

8 CheckifI(Listeveryoneinhousehold, ,childsupport, , !includingfosterandnon-fosterchildren)be foredeductionsalimonypensions,retirement i$I$I$I$ $I$I$IsI03.$I1$I~IsI04.$I1$ISIsI0~.$I1$I sIsI0[6.$I1$I::>.I~.I017.$I1$I,.I$I0. PARTIII:ENROLLMENTINFORMATION:ChildrenOn lyMychildis normallyinattendanceatthefacilitybetween thehoursof___[arn/prn]to__[am/pm]onthefo llowingdays:oCheckhereif onlybefore/afterschoolcareis provided.(Circleallthatapply).SundayMond ayTuesdayWednesdayThursdayFridaySaturday Mychildwillnormallyreceivethefollowingme alswhileincare:(Circleallthatapply):Brea kfastAMSnackLunchPMSnackSupperEveningSna ckPARTIV:SignatureandSocialSecurityNumbe r(Adultmustsign).]

9 PartII is completedtheadultsigningtheformmustalsol isthisorherSocialSecuritynumberormarkthe "Idon'thavea SocialSecurityNumber"box.(SeePrivacyActS tatementonnextpage).I certifythatall informationon thisformis trueandthatallincomeis understandthatthecenterar daycarehomewillgetFederalfundsbasedan the!informationI understandthatif I purposefullygivefalseinformation,thepart icipantreceivingmealsmaylosethemealbenef its,andI maybe (ren)listedontheformin :XPrintNameDateAddress:_CityState:GAZipP honelastfourDigitsofSocialSecurityNumber XXX-XX0I donothavea SocialSecurityNumber: PARTV:Participant'sethnicandracialidenti ties(optional)IMarkoneethnicidentity:Mar koneormoreracialidentities:IoHispanic/La tinooAsiano Whiteo BlackorAfricanAmericanoAmericanIndianorA laskaNative0 NativeHawaiianorotherIo NotHispanic/latinaPacificIslanderI OfficialUseOnly:AnnualIncomeConversion:W eeklyx 52,Every2 weeksx 26,Twicea monthx 24,Monthlyx 12!

10 Totalincome:Per:0 WeekoEvery2 weeksoTwicea montho MonthoYearHouseholdSize:---iCategoricalE ligibility:___DatewithdrawnEligibility:F reeReducedPaidTierITierIIi------------Te mporary:Free__Reduced__TimePeriod:(expir esafter___days)DeterminingOfficial'sSign ature:DateConfirmingOfficial'sSignature: DateFollowUpOfficial'sSignature:Date17 IJn1 LlTheparticipantinthedaycarefacilitymayq ualifyforfreeorreducedpricemealsif : ,butif youdonot, notrequiredwhenyouapplyonbehalfofa fosterchildoryoulistaFoodStamp,Temporary AssistanceforNeedyFamilies(TANF)Programo rFoodDistributionProgramonIndianReservat ions(FDPIR)casenumberforyourchildorother (FDPIR)identifierorwhenyouindicatethatth eadulthouseholdmembersigningtheapplicati ondoesnothavea yourchildis eligibleforfreeorreducedpricemeals, ,employees,andapplicantsforemploymentont hebasesofrace,color,nationalorigin,age,d isability,sex,genderidentity,religion,re prisal,andwhereapplicable,politicalbelie fs,maritalstatus,familialorparentalstatu s,sexualorientation,orallorpartofanindiv idual'sincomeis derivedfromanypublicassistanceprogram,or protectedgeneticinformationinemploymento rinanyprogramoractivityconductedorfunded bytheDepartment.