Foundations Child

Development Center
3375 Berkmar Drive Charlottesville, Virginia 22901
(434) 973-9218
foundationscdc@embarqmail.com
Application Date____________
Date entering center_________
Date left center______________
Childs Name___________________________
Age of child at start date_____

Nickname___________

Birth date_________

Sex_______

Address______________________________________________________
Phone Number(____)______________ Child lives with___________________
Fathers Name_________________________ name you go by _____________
Home Address (if different)______________________________________
Occupation / company_______________________
Company Address____________________________________________
Home Phone (if different) (____)__________Business Phone (____)__________
Cell #______________Pager__________ fax______________
e-mail address (please print clearly)_______________________________
Mothers Name _________________________name you go by _____________
Home Address (if different)______________________________________
Occupation / company_______________________
Company Address____________________________________________
Home Phone (if different) (____)__________Business Phone (____)_________
Cell #______________Pager__________

Fax ___________________

e-mail address (please print clearly)_______________________________

Who will likely pick up your child if he/she becomes ill during the day?
Mother________ Father________ other (please name)__________________
Status of parents: Married_, Separated_, Divorced __, Deceased__, Single___
A custody/visitation paper is attached to this form? _____yes ___no
(Please note- We cannot uphold custody arrangements without proper
documentation)
Where, or from whom, did you hear about us? ________________________

Other children in the household:

name
age
relationship to child (brother, sister, etc.)
1.
2.
3.
4.
Please answer the following questions about your child. If your need more
space, please use an additional sheet.
1. Is your child potty trained? _______Is your child in the process of being potty
trained?______ If your child is being potty trained, how are you going about it?

2. Has your child been in a preschool/day care before? If yes, where, what type
of setting was it, and for how long was your child there?____________________
3. Does your child nap? If so, what time and for how long?
____________________________________________________________
4. What time does your child go to bed? Wake up?_______________________
5. Please describe your childs appetite: _______________________________
What are your childs favorite foods? _________________________________
What foods can your child NOT eat, and why? Please let us know if your
child is on a special diet. _______________________________________
________________________________________________________________
6. Please list any allergies, food or medication restrictions, chronic
conditions etc. that we should know about:
_____________________________________________________________
7. How is your child disciplined at home? What does he/she respond to best,
least?___________________________________________________________
_________________________________________________
8. How do you anticipate your child will react the first few days of school?
_________________________________________________________
9. What are your childs interests? What things is he/she afraid of? Are there
any activities that he/she really dislikes? ________________________________
10. Please describe your childs personality, including how he/she shows that he
is happy, upset, angry. ____________________________________________

_______________________________________________________________
11. Please list anything else we may need to know about your child:
________________________________________________________________
_______________________________________________________________
12. Childs Doctor: ______________________ Practice name_____________
Address___________________________________________________
Phone number__________________________
13. Childs Dentist : ______________________ Practice name_____________
Address___________________________________________________
Phone number__________________________
14. Is child covered by health insurance? If so, please list provider, policy
number and phone number:
______________________________________________________________
Office use only:
15. State Law requires that you provide us with proof of identity within 7
business days of enrollment.
Hospital Proof of Birth letter (copy required) ____________
-orBirth Certificate # __________________Place of Birth____________________
Date issued_______________________ State / County___________________
The parents and childs names are as stated on the front sheet of application?
______ yes _______ no
I have seen the above Birth Certificate, as required by the State of VA.
Signature of administrator_________________________ Date_____________
-orI have seen the above Birth Certificate, as required by the State of VA and a
copy of the birth certificate is in the file.
Signature of administrator_________________________ Date_____________

Pick-up information:
Please list any people who are NOT allowed to pick up your child at any
time. Appropriate paperwork such as the divorce decree must be attached if a
parent is not allowed to pick up your child.
___________________________________________________________
Please list a minimum of two local people (other than the parents)
who may pick up and be responsible for your child in an emergency
situation, if you cannot be reachedYour child should know these people, and
they must be notified ahead of time that they are on your list. Emergency
situations include, but are not limited to illness, injury, or parent being more than
10 minutes late in pick-up.
(It is your responsibility to keep this list up to date! Please keep names,
phone numbers and addresses current to avoid pick-up problems.)

Unless otherwise noted on this page, these people may

also pick your child up from school without further
written or verbal permission from you.
(Required) Name________________________
Home phone_______________ daytime phone____________________
Address__________________________________________________________
relationship to child____________________________________________
(Required) Name________________________
Home phone_______________ daytime phone____________________
Address__________________________________________________________
relationship to child___________________________________

(Additional people, with all applicable information, should be listed on

another piece of paper. Please sign the list and attach it to this form)
*Please note that only the parents listed on the front page and the
people listed as pick up people in the childs file may pick up your child
unless you, in person, give written permission for someone else to do so.
We will not accept verbal phone permission, e-mail or fax , or notes
brought by the 3rd party for pick-up purposes.

Agreements: Please initial each item to show your

agreement and understanding of the policy.
________ (Initial here)
I hereby agree to place ________________________
in the care of Foundations Child Development Center on (circle) M T W TH F
(circle) full days (7 am-6:30pm). part time AM (7-12:30) or PM (1-6:30)
________
I agree to pay $___________ per week for care of this child. I
understand that should rates increase I will be notified in advance, and agree to
either pay the new rates or give 3 weeks notice of termination of this contract. I
also agree to give Foundations Child Development Center three weeks
termination notice if my child will be leaving the center for any reason. I agree to
pay for the full three weeks whether or not my child attends.
_________ I understand that I am responsible for keeping track of my childs
rate. Should my childs rate decrease for any reason it is my responsibility to pay
the lower rate. If a rate change is missed and discovered later, I understand that
the difference in payments will not be refunded or credited to me. The new rate
will take effect the first full week thereafter. This includes the rate drop at age 2.
___________ I understand that payment in full is expected before services are
rendered, and that there are no discounts or refunds if my child is absent for any
reason, including, but not limited to, illness and vacations, nor is there a discount
for weeks with 4 or fewer days due to holidays, workdays, snow days or other
emergency closings. I agree to pay any late pick-up fees charged for late pick-up
of my child. I agree to pay late payment fees if I pay after 6:30 pm Monday
afternoon of each week.
___________ I agree to pay a $35 fee for all bounced checks, and will pay the
bounced check and fee in cash or with a cashiers check within 2 days of
notification. If I have 2 or more bounced checks, I understand that all future
payments may be required to be made with cash or cashiers checks.
____________I agree to provide all required medical and immunization records
for my child prior to my childs entrance to school, and I will provide updated
immunization reports as required thereafter, or will provide necessary
documentation of medical or religious exemption from these requirements.
_____________ I give my child permission to participate in any and all of the
field trips, and agree to the transportation that Foundations Child Development
Center, Inc. deems appropriate. I give permission for my child to be
photographed at Foundations and on field trips. I give permission for photos of
my child to be used on the Foundations website and for my child to be included in
all class and school photos for sale from the school, and for school use. No
identifying information will be used on the website.

____________I agree to pick up my child within hour if he/she should become

ill while at the center, and will not send him/her back to the center until his/her
fever or other symptoms have been gone for a minimum of 24 hours to be
determined by the Director. I agree not to give my child any fever reducer 6
hours prior to bringing him or her to Foundations. Exceptions to this made be
made only by the Director. I agree to follow all illness policies.
______________ I agree to notify Foundations Child Development Center within
24 hours if my child, or another member of his/her household, is diagnosed with a
reportable communicable disease. I will notify Foundations immediately if the
disease is life threatening.
____________Should a medical or other emergency occur, I authorize
Foundations Child Development Center to obtain immediate medical care, to
provide for the arrangement of transportation to a nearby medical facility, or to
notify an emergency contact to pick up my child, as they see as necessary. I
agree to pay any medical/transportation bills incurred.
_____________I agree to notify FCDC immediately if any pick-up, address or
phone, or custody / visitation information changes, and to keep my childs file
updated at all times. I will provide updates when requested by the school, within
48 hours.
_____________I agree to pay reasonable collection and legal expenses incurred
by Foundations Child Development Center in the event I fail to pay Foundations
any amounts owed to it under this agreement.
______________ I have read in full Foundations Child Development Centers
Parent Handbook. I understand all policies and procedures and agree to follow
them as stated in this book. I understand that I am responsible for all updated
information in this book.
______________ I understand that all newsletters and weekly updates will be
sent to the email addresses provided on the front of this form.
Other agreements or acknowledgments: ________________________________
Signature of Parents or Legal Guardians
1. _____________________________________date______________
2. _____________________________________date______________
Signature of Director or Assistant Director ____________________date______
Office use : DSS scholarship _____ COPAY _________ Overmarket_______

We ask that you provide us with your social security # in the event that we need to go
through collections or the Courts to collect any unpaid fees owed to us. By enrolling
your child at Foundations Child Development Center, Inc., you agree that we can use this
number only for this purpose, and we agree to use it only for this purpose. Please fill out
the information below, which we will keep in a secure area.
In lieu of a social security number you may choose to leave with us a one months
deposit upon enrolling instead of the standard of one weeks deposit. Please notify the
Director if you wish to choose this option.
Fathers name (first) ________________ (middle) _______________(last)____________
Social security #____________________________________________________
Signature of Father __________________________________________________
Mothers name (first) _______________ (middle) _______________(last)____________
Social security #____________________________________________________
Signature of Father __________________________________________________

Deposit and Start Date Agreement:

In order to RESERVE a GUARANTEED spot we need the registration fee

AND deposit.
I, _____________________, have paid a registration fee of $_________ to
Foundations Child Development Center. I understand and agree that this
registration fee is NON-REFUNDABLE, regardless of whether or not my child
attends Foundations Child Development Center, and regardless of when
termination notice is given.
I have also paid a Deposit of $_______________, which is equal to one (circle
one) weeks / months tuition. I understand that this will be applied to my childs
last week(s) of care. I understand that no interest will be paid on this deposit. If I
increase the amount of time my child attends Foundations, an additional deposit
may be required.
I understand and agree that this Deposit is NON-REFUNDABLE, regardless
of whether or not my child attends Foundations Child Development Center,
unless I give notice in writing 4 weeks prior to the agreed upon start date to the
Director, as noted below. If there are 4 or fewer weeks prior to the agreed start
date, this Deposit is non-refundable.
Choose one:
_______ I agree that my child will start at Foundations Child Development
Center, Inc. on _____________. I agree to begin full weekly payments on this
day, even if the actual start date is delayed for any reason.
________ I am enrolling my child for the first available spot in his / her age
group. I agree that my child will start at Foundations Child Development Center,
Inc. within two weeks of spot becoming available. If I choose not to accept the
spot offered, I understand that the $75 registration fee will not be refunded.
I also agree to pay, in full, the required Deposit, as described above,
within 24 hours of the spot becoming available. Should I fail to pay this deposit,
Foundations will not guarantee the spot to my child, as they will begin
contacting others on the wait list to fill the spot.
Parent Signature _________________________Date of agreement_______________
Director Signature________________________Date