admission application

Admission Application - (Please contact us if you prefer to complete a hard copy)

Name:

Email:

Phone:

Child's full name

Child's date of birth

Child's home address

Siblings (name and age):

Name of parent or guardian completing form:

Parent A/Guardian A Info (name, address, email, phone number)

Parent B/Guardian B Info (name, address, email, phone number)

1st responsible individual to call in case of an emergency if parents/guardian cannot be reached (name and phone number :

2nd responsible individual to call in case of an emergency if parents/guardian cannot be reached (name and phone number :

Authorized Pick-up: The following individuals are authorized to pick-up my child from Elements:

Transportation Consent: I give consent for my child to be transported and supervised by the operation's employees for emergency care

Water Activities: I give consent for my child to participate in water table and/or sprinkler play activities

Receipt of written operational policies (I acknowledge receipt of the facility's operational policies, including those for: Discipline and guidance, suspension and expulsion, emergency plans, procedures for conducting health checks, procedures for parents to discuss concerns with the director, procedures for parents to participate in operation activities, procedures for release of children, immunization requirements for children, meals and food service practices, procedures to visit the center without securing prior approval, procedures for parents to contact child care licensing, dfps, child abuse hotline, and dfps website)

Days and times in care: My child will normally be in care on the following days and times (ex. Monday to Friday 8 AM to 5 PM)

I give consent for Elements to secure any and all necessary emergency medical care for my child:

Does your child have diagnosed food allergies

Does your child have an existing illness?

Has your child had a previous serious illness or injury, or hospitalization during the past 12 months?

Is your child currently taking any medications?

If so, how is the medication administered, and will it need to be administered while he/she is in care?

Is the medication prescribed for continuous use?

Are there any side effects we should be alerted to?

Does your child need assistance with toileting?

What are your ideas about toilet training?

Does your child have any special fears?

How does your child communicate his/her needs?

Are there any special words that your child uses that might not be readily recognized?

How do you tell your child to stop a behavior that you don’t approve of or that might be dangerous?

When your child gets upset, what helps him/her calm down?

Are there any particular routines that are particularly helpful at naptime?

How does your child resolve conflicts?

How can we best help with any developmental goals?

Does your child use utensils, eat with fingers, feed self?

Does your child choke easily while eating?

What activities do you like to do with your child?

What activities does your child like to do when playing with other children?

What does your child like to do when he/she is playing alone?

Tell us about your family (i.e. child’s parents, siblings, grandparents, and other extended family):

Are you interested in volunteering in any way? What skills or activities seem relevant?

Enrollment Agreement: Elements will provide methods to pay tuition by check, recurring charges on a credit/debit card and/or ACH drafts. Tuition is due on the first of each month. If tuition is late, a $10/day fee will begin on the 3rd day of the month and continue to accrue until payment is received. If you decide to withdraw your child from Elements, you must give thirty (30) days written notice prior to withdrawal. You agree to pay all tuition and fees for the thirty (30) days following your notice, even if your child is not in attendance. No refunds are issued for any tuition (including advance prepaid and/or discounted tuition) or fees as a result of withdrawal from Elements for any reason. A late pick-up fee of $1 per child is due for each minute your child(ren) remains after a 15-minute grace period. A $25.00 fee will be charged for a check returned for insufficient funds. Elements Preschool is open 8 AM to 5 PM, Monday-Friday. Elements Preschool is closed for certain holidays. The hours and holiday schedule are set and posted annually, but may be changed at any time with thirty (30) days’ notice. The tuition rates are set annually, but may be changed at any time with one hundred twenty (120) days’ notice. Your child will only be released to you or to the persons you have listed in the Authorized Pickup section of this form. Emergencies may prevent you from picking up your child; therefore, include those individuals whom you would authorize in such events. If you need to add an authorized person at a later date you must notify Elements Preschool management in advance in writing. I agree to all additional policies in the current version of the Parent Handbook.

Date completed

Child lives with (both parents, mom, dad, guardian):

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2205 Ohlen Road

Austin, Texas 78757

512-551-9849