City:

Enrollment FormPlease be sure to complete information regarding your chitd.

Personal. Familv, and Other lnformation:Child's Name: Date of Birth:Nicknames: Home Telephone:Street Address: Mailing Address:

State: Zip Code:_City:Mother or Guardian: Father or Guardian:Street Address: Street Address:

State: Zip Code: City:Mailing Address: Mailing Address:City: State: Zip Code:_City:Home Phone: Cell/Page #: Home Phone:Place of Employment: Place of Employment:Occupation: Occupation:Street Address: Street Address:City: State: Zip Code:_City:Work Hours: Work Phone: Work Hours: Work Phone:

Names, Ages and Grade Levels of Brothers and/or Sisterc:

Ca1ico Butterfl-y Preschool Children's Records Personal lnformationDate of Enrollment:Date of Disenrollment:

lamily information that is the "same" may be so noted.

Sex:

State: Zip Code:

State: Zip Code:

State: Zip Code:Cell/Page #:

State: Zip Code:

Schools, Groups, or Private Homes previously attended:

I hereby authorize the follouling person(s) to pick up my child:Name:_Relationship:_Name:Telephone: Alternate #: Telephone:

Name: Relationship: Name:Address: Address:Telephone: Telephone: Alternate # -The following person(s) may not remove my child from the center:Name:Documentation:Y/NName:-flocumentation:Y/NSignature: Telephone:

Medical and Emerqencv I nformation:ln case of injury or sudden illness, will be called first. lf medical care is necessary, call:

Phone:Doctor: AddressHealthcare Provider: Address: Phone:Hospital: Address: Phone:lnsurance Carrier: Policy Number:

Relationship:

Alternate #:

Relationship:

My child is allergic to.thesetfoods or otherlf an allergic rqaction occurs follow these procedures:My child hab thbse physical conditions: (heart trouble, foot problem, hearing impairments, hernia, infection susceptibility,convulsions, etc.):Precautions and procedures to beAdditional comments or other special instructions:

ln the event of a medical emergency, I hereby give my consent for Calico Butterfly Preschool to arrange for emergencymedical treatment necessary to preserue the health of my child and to any hospital or doctor to render immediate care andmedical treatment, including diagnostic procedures and blood transfusions, by authoized pre-hospital personnel andmembers of the hospital staff, as may in their professional judgment be necessary or in the best interest of my child's healthand safety. I hereby acknowledge that I will be responsible for all reasonable expenses in connection with the care andtreatment rendered. Signature:

lf I cannot be contacted in the event of an emergency, I hereby authoize the following person(s) to pick up my child:Name:_Relationship :_Name: Relationship:

Signature:

I acknowledge that all of the information provided on this Enrollment Form is cunent and accurate. I hereby agree to notifythe school in writing ff any of the information contained on this Enrollment Form should change duing the course of theschool year in order that att information may be cunent and accurate at all times. I will not hold Calico Butterfly Preschoolresponsible if lfail keep this information cunent and accurate. Signature:

Signature:.

Enrollment Aoreement: I hereby enrotl my child for the fottowing Catico Butterfly Preschool program services as indicated:

Discipline & Guidance Policv and Acknowledoemtent Calico Butterfly Preschool will only use positive guidancetechniques that model and encourage age-appropriate behavior and self-discipline. When problems arise, staff members willfaciliiate opportunities to co-operate, help, negoliate, and communicate to solve the situation. When neecied, chiidren will begiven a time to "sit out" for a short period (no more than 2 minutes after gaining control) at which time staff will interact withthe child to understand the consequences of their behavio/ and before being redirected or allowed to participate again.Calico Butterfly Preschool will not tolerate any method, of discipline that could cause physical, mental, or emotional, harm toyour child including corporal punishment. Calico eutterny Preschool will only communicate with the parents regardinginappropriate behavior problems when they aie ongoing or of a sedous nature that is either dangerous, or uncontrollable.Please note that Children's Christian Preschool,reserves the right to ask you to remove your child from our program(s) if it isdetermined that your child does not respond to discipline and continues to be disruptive to the class on a continual basis.t hereby acknowledge that t have read and underctand the poticies and prccedures with rcgards to disciptine.

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I understand that t need to make affangements for my chitd to be admitted and released from school on time as indicatedabove. tf I am going to be late by more than ten minutig't"aiSree to notify the school in a timely manner and understand thatif my child is picked up after 5:30 p.m. there is a fee of $10.00 for the first ten minutes and $2.00 for every minute thercafter,until my child is picked up. lf an altemative affangement for the release of my child needs to be made, I will use the followingcode word as my telephone veification for authoization. Any other person authoized to pick up my child willbe required to show identifigation' lM60 r'

I agree to paythe $ffi registration fee that is non-refundable. I also agree to submittuition as due based on the price of$-permonthforatotalof$-peryear.PaymentisduethefirctofeachmonthbeginningAugust1,

I understand that I will be responsible to pay for any additionalserylces provided by Calico Butterfly Preschool (CBP)other than fhose sfated above at the stated hourty rate of $ . There will be a $20.00 late fee for tuition submitted afterthe *day grace period. lf payment is not forthcoming for tuition outstanding in any program(s) by more than two weeks,without previous affangements made with the Director, CBP will notify you in writing that your child will be disenrolled fiom allprograms, effective the first c/ass day of the upcoming week, unless payment in full is received. CBP rcserues the ight tomake your child's space available to another student and your child will not be accepted for any fufther child care servicesuntil payment is made in full and space is available. Please note that scholarship applications are available.

I agree to the enrcllment of (child) in Calico Bufteily Preschool. We have read and agrce to complywith the policies and procedures of Calico Bufterfly Preschoolas descnbed above and in the Parent's Handbook. We agreeto submit tuition as due unless other anangements have been made with the Director of Calico Bufterfly Preschool.

Signature: Enrollment Date:

The State of New Mexico requires your child to have all age-apprcpiate vaccinations to attend school. A cunentimmunization record with a physician's signature or a valid exemption document must accompany this Form.

For CBPDTP or DtaP:4-dose seriesPolio: 3-dose series

B: 3-dose seriesHib: 3-dose series

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A: 2 dose series recommended after aqe 2

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