New Enrollment Application

CHILD INFORMATION*
First Last
SEX*
- MALE
- FEMALE
Date of Birth*
Date Format: MM slash DD slash YYYY
RACE/ETHNICITY*
- Native American
- Alaska Native
- Asian
- White
- Black or African American
- Native Hawaiian or Other Pacific Islander
- Hispanic or Latino
Please list your child's dominant language*
Does Your Child Attend School
- Yes
- No
If so, which school?
School Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Grade
School Phone
School Start Time
School Dismissal Time
Primary Parent/Guardian Information
Primary Parent/Guardian's Name*
First Last
Relationship to Child*
Phone*
Primary Residence*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Email*
Preferred Method of Contact*
Employer*
Length of Employment*
Work Address
Street Address Address Line 2 City State ZIP Code
Work Phone
Secondary Parent/Guardian Information
Secondary Parent/Guardian Name
First Last
Relationship to Child
Phone
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email
Preferred Method of Contact
Employer
Length of Employment
Work Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Work Phone
Emergency Information (This section must be completed in its entirety)
In the event of an emergency situation in which the parents/guardian(s) are unable to be reached, please list the information for two (2) adults (MUST be over the age of 18, and MUST be local) that are authorized to be notified and authorized to pick up and/or seek emergency medical attention and/or emergency care.
Emergency Contact #1
First Last
Date of Birth
Date Format: MM slash DD slash YYYY
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone
Cell Phone
Relationship to Child
Emergency Contact #2
First Last
Date of Birth
Date Format: MM slash DD slash YYYY
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone
Cell Phone
Relationship to Child
Student Release Information (All Persons MUST be over 18 years of age and present a valid picture ID)
In the spaces below, please list all persons authorized to pick up your child. Only persons listed in this area, with the exception of the parents/primary guardian AND emergency contacts are authorized. Children WILL NOT BE RELEASED to any person not listed in this section. This information can be changed at any time and must be updated as information changes. Changes over the telephone will not be accepted.
Authorization #1
First Last
Date of Birth
Date Format: MM slash DD slash YYYY
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone
Cell Phone
Relationship to Child
Authorization #2
First Last
Date of Birth
Date Format: MM slash DD slash YYYY
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone
Cell Phone
Relationship to Child
Authorization #3
First Last
Date of Birth
Date Format: MM slash DD slash YYYY
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone
Cell Phone
Relationship to Child
Anyone NOT AUTHORIZED to pick up your child:
If applicable, what is your family's child custody arrangements?
Medical Information
In the event that I, the parent/primary guardian cannot be contacted, located or communicated with in an emergency situation, this Medical Authorization releases East Gate Kids to obtain the necessary emergency services to treat my child in the event of illness or injury while in the care of East Gate Kids. I acknowledge that it is necessary to give consent and permission to East Gate Kids to act on my behalf in the event that I am unable to be located and emergency services are necessary.
In the event of illness or injury, I acknowledge that all reasonable efforts will be made to contact me to obtain my consent in advance of medical services to be rendered. Selection of a physician and/or hospital will be made according to the Application of enrollment, completed by me at the time of enrollment into East Gate Kids. If I have failed to complete this information, I hereby authorize East Gate Kids to transport my child to the nearest hospital or medical facility consistent with the circumstances at the time of my child’s illness/injury. I acknowledge that accidents and/or illnesses are first attended to by the staff of East Gate Kids and the appropriate first aid supplied.
In an effort to avoid difficulties or unnecessary delays in obtaining emergency medical treatment in the event of accident or illness, I acknowledge that this Medical Authorization gives my consent and permission for East Gate Kids and/or its designee to obtain the necessary emergency medical treatment and/or transportation of my child to the appropriate medical facilities in the event of an emergency. I hereby assume financial responsibility for any hospitalization, medical treatment and/or surgery provided.
Parent/Legal Guardian Name
First Last
Name of child's physician:
Phone
Hospital affiliation
Please list any known allergies or medical conditions (please write "None" if applicable)
Date
Date Format: MM slash DD slash YYYY
Financial Responsibility
FINANCIAL RESPONSIBILITY (check one below) AS OF JANUARY 2020 TUITION IS DUE BY THE 1^TH OF EACH MONTH WITH A TEN DAY GRACE PERIOD UNLESS OTHER ARRANGEMENTS HAVE BEEN MADE.
Do you have a CYFD contract?
- Yes
- No
If yes, your monthly co-pay is:
If yes, your weekly contract schedule and hours are:
Are you enrolling for the Free NM Pre-K? (Hours between 9am-3pm Mon-Fri)
- Yes
- No
Will you be a private pay (self-pay) client?
- Yes
- No
If private pay, what would you like your weekly scheduled hours to be?
Monday Tuesday Wednesday Thursday Friday
For families that have multiple children in the center and are self-pay, your monthly tuition has been figured in the following manner:
- Two children receive a 10% discount off your total monthly tuition
- Three children receive a 15% discount off your total monthly tuition
- Four or more children receive a 20% discount off your total monthly tuition
Registration fees of $60.00 per child are due upon admission and are NON-REFUNDABLE. After the initial enrollment, this $60.00 becomes an annual curriculum fee, which is due September and/or upon every re-enrollment.
Please provide names and ages for siblings enrolled at East Gate Kids:
When payment has not been received by the 10^th of the month or by your arranged payment date, a $5.00 a day late fee will be applied to your account
All payments are to be made to East Gate Kids by check or money order. All tuition contracts for self-pay customers are effective from August 1 through July 31. The tuition contract for those children enrolled in our Before and After School program, runs from August 15 through May 31. In June, our summer program will take effect for those children ages 5* - 12. (*must have completed Kindergarten). For those choosing to enroll in our summer program, a weekly fee of $145.00 You will not be charged during the summer program (ages 6-12) for weeks your child does not attend. However, you will need to submit these dates in writing in order to receive credit during the summer.
For those children ages six (6) through five (5) years (whom have not completed Kindergarten), please refer to the sheet title “Tuition Rates” for any questions concerning your tuition rate. You are responsible for payment of tuition each month as stated on your financial obligations form. If any of the above information is incorrect, please notify the director immediately so that we can make the necessary corrections. Parents are responsible for the above stated tuition until a WRITTEN disenrollment notice (requires a two-week notice) or change in status notice (will be effective at the beginning of the following month) is given to East Gate Kids.
I understand the above tuition contract: (Type your name below)
First Last
Policy and Agreements

EXCLUSIONARY POLICY

In order to protect our staff, children, and families, it may become necessary for East Gate Kids to temporarily exclude a child from our facility. If any of the following symptoms are observed in your child during the school day, your child will need to be picked up from the center.

· A fever of 100.3 or higher

· Vomiting

· Diarrhea

· Any form of rash

· Drainage from the eyes, ears, nose, or any open sores

· Uncontrollable coughing, wheezing or difficulty breathing

For your child’s health and comfort, we ask that you make a reasonable effort to arrive one hour from the time we contact you. Your child will not be allowed to return until you can provide a verifiable doctor’s note indicating that your child is not contagious and may participate in all center activities or until your child has been symptom free for at least 24 hours without medication.

Additionally, we ask that you PLEASE notify us as soon as you have a confirmed diagnosis of your child’s illness. This will help us to alert other families of possible symptoms for which they should be aware of.

Permission to Photograph and Video
Photographs and/or video recordings will be taken, from time to time, while your child is enrolled with East Gate Kids. These photographs and videos may be used for educational or promotional purposes, displayed in classrooms, EGK facility, posted on EGK website, Facebook or Instagram and may be used as an educational brochure.
I understand that it is my responsibility to update this form in the event that I no longer wish to authorize the above uses. I agree that this form will remain in effect during the term of my child’s enrollment.
I give East Gate Kids permission to photograph my child(ren):
- Yes
- No
I give East Gate Kids permission to video my child(ren):
- Yes
- No
Parent E-Signature
First Last
Parent Agreement

1. East Gate Kids (EGK) is an equal opportunity provider. Children are accepted without regard to race, religion, color, national origin or sex.

2. EGK is open from 6:30 am to 6:00 pm Monday through Friday on a year round schedule except for the following holidays:

· New Year’s Day

· Presidents’ Day

· Good Friday

· Memorial Day

· Independence Day

· Labor Day

· Thanksgiving Day and the Friday after

· Christmas Eve

· Christmas Day.

There is no tuition credit for holidays. East Gate Kids follows the APS weather schedule. If there is a 2-hour delay, East Gate Kids will open at 8:30 am. If APS closes for the day, East gate Kids will be closed also. In the event that APS is not in session, East Gate Kids will modify its schedule at its discretion. Please follow KOB channel 4 or KOB.com for closure listings under East Gate Kids.

3 All tuition payments are due by the 1^ST of each month with a ten-day grace period unless other arrangements have been.

A $5.00 a day late fee will be assessed to tuition not paid by the 10^th of the month. The child will not be accepted if tuition is not paid by the 10^th of the month.

$11.00 Hourly Drop-In tuition is due on the day of the drop in.

Any exceptions to this policy will have to be evaluated by EGK’s Director.

Returned check fee charges of $20.00 will be the responsibility of the parent and will be added to the monthly bill. EGK will include the costs of collection through an attorney to the amount of any delinquent account. Families should anticipate an annual rate increase.

4 Parents are to leave their child in the care of an East Gate Kids employee. For the safety of the children, parents are to pick up and drop off their children in the classroom. Each child is to be signed in and out on the lobby computer as well as in the classroom. If you have more than one child, they must stay with you while you pick up your other children. They may not run around the building unattended. Children will not be released to any relative or friend who is a minor.

5 EGK provides breakfast, lunch, and an afternoon snack. Infant cereal and jar food are supplied by East Gate Kids, as well as Member’s Mark Infant formula. In the event that your child uses a different product than we provide, we ask that you bring in your child’s brand of formula.

6. Each child shall have a change of clothing. Each clothing article provided for your child should be clearly labeled.

7. Children are not to attend EGK if they have vomiting, diarrhea, fever, chicken pox, or other communicable conditions. A child is to be picked up by the parent if they develop symptoms during the day, which are assumed contagious or need medical attention. EGK will need a written release from a physician if the child develops certain diseases, which are monitored by the New Mexico Department of Health. A list of these diseases is posted on the parent board. Children may return to EGK after they have been fever free for 24 hours without the aid of fever reducers, have been on antibiotics for 24 hours or with a doctor’s note stating it is safe for the child to return to the center.

8. No reduction of tuition will be granted to vacation, illness or holidays. If a child withdraws for a period of time, readmission will be accepted on a space availability basis after payment of all required fees.

9. EGK may withdraw a child immediately whose condition or behavior interferes with the appropriate operation of EGK.

10. EGK may withdraw a family immediately if an adult’s behavior is seen as abrasive or confrontational and/or inappropriate in a child-centered environment

11. This parent agreement may be changed with two weeks’ notice. Any changes will be posted in the EGK entrance.

12. Registration fees of $60.00 per child are due upon admission and are NON-REFUNDABLE. After the initial enrollment, this $60.00 becomes an annual curriculum fee, which is due September 1^st and/or upon every re-enrollment.

13. All tuition is non-refundable. A two-week written notice is expected prior to withdrawal from EGK. If a two-week notice is not given, any remaining balance must be paid in full in order to avoid your balance being turned over to collections.

14. In the event of an emergency, EGK had my permission to administer first aid or obtain emergency medical treatment, including transportation by ambulance or by other means necessary to suit the child’s best interest. I agree to pay all expenses incurred due to an emergency involving my child.

15. Please do not allow your child to bring personal items and toys. These often cause a disruption in the classroom. EGK will not be held responsible for lost or broken personal items brought to EGK, including jewelry, CD’s, toys, electronics, etc.

16. Parents of school-aged children are to notify EGK if we are not to pick up their child from school. Parents who fail to call will be charged a $5.00 fee each time.

17. I agree to pay a late pick up fee of $5.00 for the first minute and $1.00 each minute thereafter per child left at EGK after 6:00 pm. Late fees must be paid before your child can attend the next day. It is our policy that we call the authorities if any child is left at EGK after 6:30 pm REGARDLESS if you have called to say that you will be running late.

Policy Acknowledgments (Please type your initials below each statement)
I understand that the Registration fee of $60.00 must be paid at the time of enrollment. This fee is non-refundable.
I understand and Acknowledge that I have received a copy of the current Tuition Agreement and I agree to the terms stated therein.
I understand that tuition paid is for current month services.
I understand that my child’s monthly rate is the rate until my child is promoted to the next age classroom.
I understand that late fees are assessed to my account if my payments are not received by the stated date in the Tuition Contract.
I understand that I must give a two (2) week disenrollment notice, in writing, to East Gate Kids prior to disenrolling my child from care. Regular tuition is due during this two (2) week period.
I understand that overtime fees will be assessed to my account if my child is not picked up at East Gate Kids prior to closing at 6:00 pm, Monday through Friday. Charges are as follows: $5.00 for the 1st minute and $1.00 per minute thereafter. East Gate Kids operating hours are 6:30 am to 6:00 pm.
I understand and agree that a $20.00 returned check fee will be automatically assessed to my account for any returned checks to cover processing fees.
I understand and acknowledge that there are no refunds of the registration fees, disenrollment fees, late fees, returned check fees and tuition fees.
I acknowledge that I have completed a Medical Release form authorizing East Gate Kids to obtain emergency medical treatment for my child.
I acknowledge and agree to provide up-to-date immunization records for my child prior to the first day of attendance in accordance with the laws of the State of New Mexico.
I understand and acknowledge that East Gate Kids is unable to administer medications of any kind, including sunscreen, to my child without my written permission in accordance with the laws of the State of New Mexico. Medication authorization slips must be completed prior to or on the day medication is to be administered. All medications must be in their original containers and clearly labeled with dispensing instructions. Verbal authorization is not permitted.
I acknowledge receipt and understanding of my financial responsibilities of this enrollment agreement (for East Gate Kids or State of NM), and state that I have read and thoroughly understand the policies and agreements of East Gate Kids and agree to the terms and conditions stated in these materials.
Parent/Legal Guardian E-Signature
First Last
I hereby acknowledge and state that the information contained within this Application of enrollment has been completed accurately to the best of my knowledge. I hereby agree to update this information as it changes and at least once a year thereafter.
Parent/Legal guardian E-Signature
First Last
Date
Date Format: MM slash DD slash YYYY
For Office Use Only:
Date of enrollemnt
First date of attendance
Disenrollement Notice
Last date of attendance

Monday	Tuesday	Wednesday	Thursday	Friday

Primary Parent/Guardian Information

Secondary Parent/Guardian Information

Emergency Information (This section must be completed in its entirety)

Student Release Information (All Persons MUST be over 18 years of age and present a valid picture ID)

Medical Information

Financial Responsibility

Policy and Agreements

Permission to Photograph and Video

Parent Agreement

Policy Acknowledgments (Please type your initials below each statement)

For Office Use Only: