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Enrollment

Please note that the submission of this application does not constitute enrollment.
It will notify the center of your interest. Please visit the center in person to complete the enrollment process.
 
* Denotes a required field
First Parent:
First:*
Last:*
Address:*
City:*
ST:*
Zip:*
Home Phone:*
SSN:*
Employer:*
Em. Address:
Work Phone:Ext:
Email Address:
Second Parent:
First:
Last:
Address:
City:
ST:
Zip:
Home Phone:
SSN:
Employer:
Em. Address:
Work Phone:Ext:
Email Address:
Child Information
First:Last:Date of Birth:Gender:SSN:
Child #1:*
Child #2:
Child #3:
Child #4:
Contacts:
Name:Address:Phone:Relationship:Authorized to pick up:
Contact #1:
Contact #2:
Contact #3:
Contact #4:
Address (If different from parent address above):Phone:
Family or Person that referred you to Apple Tree:
Attendance Data:
Start Date: ... Days Attending:Time of Day: ... to ...
Meals your child would be in attendance for:
Apple Tree Hollidays:Memorial Day • July 4th • Labor Day • Thanksgiving • Christmas Eve • Christmas Day • New Years Day
Medical Information:
Address:Phone:Nework Provider:
Physician:*
Dentist:*
Please list any restrictions, chronic conditions, allergies or dietary restrictions that we should know about your child
Insurance Provider:*Policy #:
STATEMENT OF INSURANCE COVERAGE: Our centers carry adequate accident and liability insurance. In the event that your child is involved in an accident while at our center and requires medical attention, our Supplemental Accident Insurance covers any amount that your insurance will not pay, up to $1,000.00.
 
Please Check the following items to show agreement:
*A signed copy of required immunizations is submitted with enrollment and will be updated as necessary.
*I certify that my child is enrolled in a regular medical program and has been examined by a doctor within the last 12 months.
*I understand that Apple Tree Children’s Centers follow a State recommended health policy of which I have received a copy. I agree that 1) A child who appears ill upon arrival shall not be admitted to the center. 2) When a child becomes ill at the center, the parents shall be contacted and arrangements made for the child to be picked up immediately. This determination will be made by the center. 3) The center may require a physician’s statement prior to readmitting my child to the center following an illness. 4) At the time of registration, the parents shall authorize the child’s physician to accept all calls from the child care director for emergency medical care.
*I hereby authorize Apple Tree Children’s Centers to take my child to the Physician or facility, as referred on the first page, for medical treatment in the event of an emergency in which neither parent nor emergency contact can be reached.
*I hereby authorize any licensed physician or medical treatment center to treat my child in case of an emergency in which the above named physician cannot respond.
History
Please let us know about your child, ie: nickname, favorite relative or friends they may talk about; other centers or child care experiences; dressing, napping routines; how does he/she handle separation from parents; any special fears or problems; how does he/she communicate bathroom needs; etc. If your child shares living arrangements with more than one household, is there a determined schedule. Any other information that you feel is important for us to know in order to provide the best possible care for your child:
*I give permission to Apple Tree to incorporate my child’s image for any purpose Apple Tree deems proper. This may include advertising, and publicity including television and newspaper reports.
*I hereby authorize Apple Tree to include my child in supervised water activities.
*I hereby authorize Apple Tree to transport my child to or from school, on educational excursions, or on other center sponsored activities.
Policy:
REPORTING POLICY:
South Dakota Law (SDCL 26-10-10) mandates all licensed or registered child care providers to report any suspected incident of child abuse or neglect to the Dept. of Social Services or Law Enforcement. Reportable incidents include suspected abuse/neglect within this group care center.
 
CHILD ABUSE POLICY:
Any staff member or volunteer who feels that a child in placement may have been abused or neglected at home or in the center is to immediately report her/his feelings to the director or to the individual who is designated as the supervisor. After verbally reporting the incident to the director or her designee, the employee/volunteer is to document in writing what he/she observed. This report is to include the date of the incident, time, those involved, and a statement of what was observed. This written report is to be given to the director or the designee. Upon receiving the verbal report, the director/designee is to immediately:
1.Report the incident to the Dept. of Social Services or Law Enforcement.
2.Incase of in-center child abuse, the staff member/volunteer will be dismissed immediately.
3.In the case of suspected in-house child abuse/neglect, determine if the children are safe pending the investigation. If a staff member/volunteer is involved, suspension may occur to protect children.
4.Cooperate with the Dept. of Social Services and/or Law Enforcement throughout the investigation.
*I have read the above policies and am in agreement.  Name:
Note that the submission of this application does not constitute enrollment. It will notify the center of your interest. Please visit the center in person to complete the enrollment process.
 



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