Application form UPK

UNIVERSAL PRE-K
ADMISSION APPLICATION FORM

CHILD’S INFORMATION

1. NAME 2. DOB 3. SS #

4. ADDRESS Street Apt#
City ZIP code

5.HOME PHONE # 6.Email:

7.FAMILY DOCTOR: 8.DOCTORS PHONE #

PARENT’S INFORMATION

9. MOTHER’S NAME 10. PLACE OF WORK

11. BUSINESS PHONE Cell Phone

12. FATHER’S NAME 13. PLACE OF WORK

14. BUSINESS PHONE Cell Phone

15. Does your child need bus transportation service: (Please check):  Yes No

16. Name of person/people you authorize to pick- up child from the day care center/bus stop:

17. HOW DID YOU HEAR ABOUT US:  Friends Newspaper Radio/TV Internet Other

18. RELATIVES OR FRIENDS PHONE # TO CONTACT IN CASE OF AN EMERGENCY:

CONSENT FOR EMERGENCY MEDICAL TREATMENT

I do hereby give authority to the BECEC Inc., d/b/a/ BAMBI DAY CARE CENTERS staff to obtain necessary emergency medical treatment for my child with the understanding that the family will be notified as soon as possible.

Signature  Ok Relationship - Date:

DAY CARE REGISTRATION CONTRACT

I, residing at agree to register my son/daughter with BECEC Inc., d/b/a/ BAMBI DAY CARE CENTER for:

 UPK FULL DAY PROGRAM (8:30-2:50)

I understand that NYC DOE covers all of the expenses for attendance of my child for the UNIVERSAL PRE-K PROGRAM of the day care center at BECEC Inc., d/b/a/ BAMBI DAY CARE CENTERS, use of all programs, educational instructions, supervision, educational materials, toys, participation in all day care center activities, daily meals (breakfast, lunch). The Universal Pre-K program funds provided by the NYC Department of Education do not apply to the extended day programs of BECEC Inc., d/b/a/ BAMBI DAY CARE CENTERS.

 EXTENDED DAY PROGRAM (7:30-8:25AM & 2:55-7:00 PM)

I undertake to pay $ per month as a tuition fee for the EXTENDED DAY PROGRAM. The tuition is due the first of each month (late payment charge of $50 will be added for payments made after 5 th of each month..)
Non Refundable registration fee of $100 required upon registration (extended day program only).

I understand that this amount covers expenses for attendance of my son/daughter of the day care center at BECEC Inc., d/b/a/ BAMBI DAY CARE CENTERS, during non UPK hours (extended day program), including all NON ATTENDANCE UPK DAYS, recess, and Government Holidays the Day Care Centers are officially open. I also understand that there will be no deductions made for any absence in case of illness, vacations or other reasons. Full tuition payments are due regardless of government or religious holidays noted in the Day care center Annual Calendar.

I understand that for the safety, welfare and proper maintenance of all students, the BECEC Inc., d/b/a BAMBI DAY CARE CENTER reserves the right, in its sole discretion, to suspend or expel students whose conduct or influence is damaging and/or potential dangerous to the safety of students, staff or day care center property. The BECEC Inc., d/b/a BAMBI DAY CARE CENTER reserves the right to determine the severity of the disciplinary issues and threats to the safety of its students, in its sole and absolute discretion. Some egregious examples of misconduct include but are not limited to: physical violence toward students and day care center staff, damage or defacing of day care center property, theft, and inappropriate behavior. On the part of the parent, childcare fees are 10 days or more delinquent, an obvious misrepresentation regarding the medical or mental history of a student, will result in action to be taken against the student that may include dismissal from the day care center. The previously stated examples of misconduct are just examples and BECEC Inc., d/b/a BAMBI DAY CARE CENTER may deem other conduct or misrepresentation as damaging or dangerous, in its sole and absolute discretion. All of the abovementioned disruptions to the safety standards of the BECEC Inc., d/b/a BAMBI DAY CARE CENTER., may lead to the student’s dismissal from the day care center. The BECEC Inc., d/b/a BAMBI DAY CARE CENTER administrative staff reserves the right to make judgments upon disciplinary action, in its sole and absolute discretion, to be taken against a student (including suspensions or dismissals).

BECEC Inc., d/b/a BAMBI DAY CARE CENTER assumes no responsibility for the acts done by students when in violation of day care center rules, local, State or Federal laws. BECEC Inc., d/b/a BAMBI DAY CARE CENTER is not responsible for losses of personal property or acts done by students or other persons while off day care centers premises and the undersigned parents, agree to indemnify and hold harmless BECEC Inc., d/b/a BAMBI DAY CARE CENTER its officers, directors, partners, employees and agents, from and against all claims, actions, damages, liabilities, losses, costs and expenses, including attorney fees, that arise out of or in connection with acts done by students in violation of day care center, local, State or Federal laws.

I hereby consent to the participation in interviews, the use of quotes, and the taking of photographs, movies or video tapes of the Student named above. I also grant to BECEC Inc., d/b/a/ BAMBI DAY CARE CENTER the right to edit, use and reuse said products, purposes including use in print, on the internet, and all other forms of media.
I also hereby release the BECEC Inc., d/b/a/ BAMBI DAY CARE CENTER and its agents and employees from all claims, demands, and liabilities whatsoever in connection with the above.

I hereby confirm that the above named child is in good physical condition and has been examined by a physician within the past 6 (six) months and is in relatively good health and able to participate in a full to BECEC Inc., d/b/a/ BAMBI DAY CARE CENTER educational and sports programs.

In cases of extreme emergency, I give permission to the physician or hospital selected by the BECEC Inc., d/b/a BAMBI DAY CARE CENTER officials to hospitalize, secure proper treatment for, order injections, anesthesia, X-rays or surgery to my child. I understand that the cost of medical services will be entirely my responsibility. I understand that the BECEC Inc., d/b/a BAMBI DAY CARE CENTER will make every effort to contact me or another designated emergency contact person before or immediately after such emergency treatment is rendered.

I understand that BECEC Inc., d/b/a/ BAMBI DAY CARE CENTER will make every effort to contact my emergency contact or myself before or immediately after such emergency treatment is rendered.
Parent/guardian further agrees to waive the right to press legal charges against BECEC Inc., d/b/a/ BAMBI DAY CARE CENTER, its officers, directors, and employees, in those instances where any of the above have not clearly demonstrated negligence leading to injury of the above named child.

I understand that I have to pick-up my child at or before 6 PM from day care center premises in case he/she does not use bus services.

If child is out of day care center sick for more than 3 days parents are obligated to submit a doctor’s notice upon the child’s return.

Parents must notify day care center’s office in writing for all changes of address, telephone numbers, and emergency contacts not later than 7 business days after changes occur.

I have read and understood the Agreement of the Enrollment terms, which have been presented in the Agreement. I agree to all terms contained in the Agreement. In agreeing to the terms presented in the Agreement, I acknowledge that I am also acting on the behalf of the other parent/legal guardian (if that person is not present at the signing of the Agreement) with the authority to enroll my child in to the BECEC Inc., d/b/a/ BAMBI DAY CARE CENTER and agree to execute this agreement on his or her behalf. I recognize that the BECEC Inc., d/b/a/ BAMBI DAY CARE CENTER relies upon the representation herein made in accepting my child to the BECEC Inc., d/b/a/ BAMBI DAY CARE CENTER

Parent’s Signature  Ok Date:


EMERGENCY MEDICAL RELEASE AGREEMENT

As the parent or legal guardian of:

I, give my permission for my child to receive whatever emergency medical care that may be needed to BECEC Inc., d/b/a/ BAMBI DAY CARE CENTER personnel for the treatment of any injury that may be incurred while in the activity of swimming on premises or elsewhere.

I understand that BECEC Inc., d/b/a/ BAMBI DAY CARE CENTER will make effort to contact myself or my emergency contact before or immediately after such emergency treatment is rendered.

Signature:  Ok

Date:


MEDICAL INSURANCE INFORMATION

NAME OF PRIMARY INSURER

NAME OF CHLD’SMEDICAL INSURANCE COMPANY

CONTRACT# GROUP# ID#

LIMITED WAIVER OF LIABILITY

BECEC Inc., d/b/a/ BAMBI DAY CARE CENTER provides serious education, recreation and sport programs including swimming. Our staff is trained to provide the maximum of protection for your child while in our care. Even with all of these safeguards injuries can occur.

As a parent or legal guardian of the above named student, I fully understand the risks involved in my child’s participation in the all day care center activities. To the best of my knowledge my child has no medical conditions, which would conflict with his/her participating in the to BECEC Inc., d/b/a/ BAMBI DAY CARE CENTER education, sport and recreation programs. I further agree to waive the right to press legal charges against to BECEC Inc., d/b/a/ BAMBI DAY CARE CENTER, its officers and staff, in those instances where any of the above have not clearly demonstrated negligence leading to injury of the above named student.

Signature  Ok

Date


TRANSPORTATION REQUEST FORM

The undersigned parent(s) or legal guardian(s) of hereby authorize BECEC Inc, d/b/a BAMBI DAY CARE CENTER (“Organizers”), to facilitate the procurement of bus transportation for my son/daughter for the 202 - 202 school year. In their role as facilitators, I/we hereby authorize Organizers to enter into a Pupil Transportation Services Agreement with Academy Transportation Inc. on my/our behalf. I/we shall remit payment for Student’s bus transportation in accordance with the payment schedule specified by Organizers. I/we acknowledge that failure to remit payment on a timely basis may result in termination of bus transportation for Student(s). I/we acknowledge that we will not remain responsible to the payment for bus transportation if it is not used.

I/we hereby indemnify and hold Organizers harmless from all costs and expenses incurred by them arising from the failure of the undersigned to pay for the bus transportation for the Student(s). I/we hereby release Organizers and shall hold them harmless for the acts or omissions of Academy Transportation Inc. in the performance of the bus transportation services for Student(s).

PARENT/GUARDIAN INFORMATION:

Parent’s Name:
Address:
City State Zip Code
Home phone# Work Phone # Cell Phone#

STUDENT INFORMATION:

Child’s Name:


SCHOOL BUS TRANSPORTATION LIABILITY WAIVER

As parent/guardian of the above named child/children, I hereby release the BECEC Inc, d/b/a BAMBI DAY CARE CENTER, its agents, employees and trustees from all liability arising out of his/her transportation on the school bus to or from the BECEC Inc, d/b/a BAMBI DAY CARE CENTER and throughout all the extra curriculum activities including daily trips.

As parent and/or legal guardian, I remain legally responsible for any personal actions taken by the above named student. I agree on behalf of myself, my child named herein, or our heirs, successors and assigns, to hold harmless and defend BECEC Inc, d/b/a BAMBI DAY CARE CENTER, its officers, directors and agents, and the chaperones, or representatives associated with the event, from any and all actions, claims, demands, damages, costs, expenses and all consequential damage arising from or in connection therewith, and I agree to compensate the day care center, its officers, directors and agents, chaperones, or representatives associated with the event for reasonable attorney’s fees and expenses arising therewith.

I understand that it is my full responsibility as parent/guardian to:

  • •Place him/her on the bus in the morning, and to meet him/her in the evening at the bus stop.
  • Be on time for the evening pickup.
  • Instruct my child/children as to his/her pickup and drop off point.
  • •Review with my child/children the School Bus Rules provided by the day care center.

Parent(s) Signature:  Ok     Date:

STUDENT RELEASE FORM

BECEC INC, D/B/A BAMBI DAY CARE CENTER., recommends all participants obtain a physical examination from their physician prior to participating in any or all programs provided by BECEC INC, D/B/A BAMBI DAY CARE CENTER., or its affiliates.

1. The educational programs at BECEC INC, D/B/A BAMBI DAY CARE CENTER., requires the participant to perform a great deal of physical exertion, including sprints, hand-eye coordination activities, and agility drills. This form of exercise directly affects heart rate, body temperature and respiration, and requires the participant to be in good physical condition. It is up to the participant, or parent/guardian, to ensure that he/she is physically capable and in good mental condition, so as to permit safe participation in the program. BECEC INC, D/B/A BAMBI DAY CARE CENTER., shall have no responsibility, nor liability to confirm the medical condition of a participant. The undersigned recognizes the possible dangers connected with physical activity and competition and it is expressly agreed that participation in the program shall be undertaken at the participant’s own risk. In consideration of the undersigned’s participation in the program, the undersigned hereby certifies and represents that he/she is in good medical condition and is physically capable of safely participating in the program, and utilizing all exercise equipment, athletic equipment, and training required in the program.

2. The undersigned hereby releases BECEC INC, D/B/A BAMBI DAY CARE CENTER., it’s directors, employees, agents, representatives, coaches, and volunteers, as well as the owners of any facilities in which the program is conducted, on behalf of himself/herself and any one claiming by, through or under the undersigned, from any and all claims of damage, injury, or death, of any kind, arising out of the undersigned’s participation in the program. In addition, the undersigned acknowledges and agrees to indemnify and hold BECEC INC, D/B/A BAMBI DAY CARE CENTER., harmless from any claims of damage, injury or death arising out of the participation of the undersigned in the program, including injuries caused in whole or in part by the undersigned, or another participant.

Moreover, by this release, the undersigned also intends to fully, completely and forever release, discharge, and absolve BECEC INC, D/B/A BAMBI DAY CARE CENTER., all of its directors, employees, agents, representatives, coaches, and volunteers, from any active or passive negligence whatsoever on the part of BECEC INC, D/B/A BAMBI DAY CARE CENTER., its directors, employees, agents, representatives, coaches, and volunteers. The undersigned further agrees and promises not to sue or exercise any legal rights to seek damages or relief of any nature from BECEC INC, D/B/A BAMBI DAY CARE CENTER., its directors, employees, agents, representatives, coaches, and volunteers. The undersigned certifies that he/she has read this release and all of the statements contained herein, and further represents that he/she understood its contents and has voluntarily executed this release. The undersigned understands that he/she is giving up valuable rights and is signing this release voluntarily. The undersigned further agrees that no oral representations, statements, or inducements of any kind apart from this written release have been made with regard to the subject matter of this release.

3. The undersigned hereby warrants that he/she is over the age of eighteen, is competent to contract in his/her name, and that the undersigned has the authority to grant this consent and release.

Signature:  Ok

Relationship if participant is minor:


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