Your child may be released to the following person(s):
Name:
Address:
Contact #:
Relationship:
Emergency Contact in case parents cannot be reached:
Name:
Address:
Contact #:
Emergency Physician Contact:
Name:
Address:
Contact #:
ADMISSION INFORMATION
HEALTH REQUIREMENTS
Name of Child:
Date of Birth:
IMMUNIZATIONS
Date/dose 1
Date/dose 2
Date/dose 3
Date/dose 4
Date/booster
DTP / DTaP / DT
POLIO IPV or OPV
MEASLES Rubeola / Scrampion
MUMPS
RUBELLA
Hib
Hepatitis A
Hepatitis B
TB TEST (if required)
Varicella (see below)
Varicella (chicken pox) vaccines not required if your child has had chikenpox disease. If your child has had chickenpox,
please complete the statement: My child had varicella disease (chickenpox) on or about (date)
and does not need varicella vaccine.
________________
Parent’s Signature
Date
Signature of Health Care Professional: ________________________________
Date:
ADMISSION REQUIREMENT: If your child does not attend pre-kindergarten or school away from the child-care operation, one of the following must be presented when your child is admitted to the child-care operation or within one week of admission.
Please check only one option:
1. HEALTH-CARE PROFESSIONAL’S STATEMENT: I have examined the above named child within the past year and find that he/she is physically able to take part in the day care program.
Health Care Professional’s Signature:________________________________ Date:
2. A signed and dated copy of a health care professional’s statem,ent is attached.
3. PARENT’S STATEMENT: My child has been examined within the past year by a health care professional and is able
to participate in the day care program. Within 12 months of admission, I will obtain a health care professional’s
signed statement and will submit it to the child-care operation.
Name and address of health care professional:
Signature: Parent of Legal Guardian: ________________________________ Date:
4. Medical diagnosis and treatment conflict with the tenets and practices of a recognized religious organization, which will ad here to or am a member of; I have attached a signed and dated affidavit stating this.
V ISION
R 20/
L 20/
PASS
FAIL
Signature: ________________________________ Date:
HEARING
1000 Hz
2000 Hz
4000 Hz
R
L
PASS
FAIL
Signature: ________________________________ Date:
Signature: Parent of Legal Guardian: ________________________________ Date:
MEDICAL RELEASE FORM
Name of Child:
Doctor’s Name:
Telephone #:
I hereby grant Brilliance Pre-School and Academy permission to seek medical attention for my
child in the event of an emergency and I am unable to be contacted. I further consent to medical
or surgical treatment by any licensed physician and/or hospital. I also permit administration of
necessary anesthetics, medical treatments, tests or drugs, and the performing of whatever
operation may be necessary or advisable.
EMERGENCY MEDICAL INFORMATION
Drug Allergies:
Chronic Diseases / Other Health Problems:
Insurance Covereage (if any):
Blood Type:
Parent’s Signature:
Date:
Witness:
PARENT UNDERSTANDING OF SCHOOL POLICIES
Please read the following policies carefully, check the box, and sign/date at the bottom:
I will inform the school promptly of any changes to my address, phone numbers or child’s pick-up information.
I understand that my child will only be released to parents or those designated by parents on the child’s enrollment form.
I understand that the tuition is an annual tuition and it is broken down into ten payments according to the school year (August - May).
I understand that tuition will not be pro-rated during the school year for in-service days;
vacation, illnesses and bad weather days. (Please refer to the Closing and Holiday
Schedule)
I understand that tuition will be prorated during the summer months of June and July only for planned vacation and that credit will be given toward tuition for the following month.
I agree to pay the monthly tuition plus after school care fee by the first of each month.
I understand that a late charge of $30.00 will incure as late tuition if paid on or after the 4th of the month and $50.00 if tuition is paid on or after 10th of the month.
In the event of returned check, Brilliance Academy will charge a fee of $35.00, plus a late
fee payment. I agree to pay the initial check amount with the returned fee and late fee
payment by cashiers check or money order.
I agree to pay $5.00 per hour if my child is not picked up by 3:45 p.m. (applicable only to children enrolled until 3:45 p.m. only).
I understand that to withdraw my child, I must provide one month’s notice or forfeit a month’s
tuition. The last month’s tuition will be paid by cashiers check or money order. If notice is not
provided, and tuition is not paid, Brilliance may forward these arrears to the District Attorney
or to a collection agency.
I understand that Brilliance Academy reserves the right to dismiss my child if his/her
behavior is disruptive to the class or results in destruction of property. (Brilliance Academy
will follow the process of informing parents verbally at first then, through a written memo).
I understand that to transfer from full-time enrollment to part-time enrollment, one month’s
notice must be given. I understand that no transfers are available during the months of March,
November, and December.
I understand that the Brilliance Pre-School and Academy is a ‘School’ that teaches academics
to young children and also provides extended child care services. It is not a drop off center or
a weekly child care/day care service center.
I agree to work hand in hand with the teachers and administrators to provide the support my
child requires in developing his/her social, physical and intellectual skills.
I agree to provide the school with all necessary information pertaining to administering
medicine to my child.
I understand my child will be provided with snacks and lunch served at school however, I am totally responsible for any special diet required by my child.
I understand that according to the school’s regulations, it is my responsibility to escort my child in and out of the school.
I understand that in the event of a medical emergency: First Aid/CPR will be administered,
911 will be called and then the parent/emergency contact will be contacted. In the even
that your child must be transported to the nearest medical facility, a staff member will be
with your child until a family member arrives (The parent will assume responsibility for
payment).
I understand that if my child is ill, including, but not limited to, a severe cough or sore
throat; undetermined rash or spots; temperature over 100 degrees Fahrenheit; severe
headaches, upset stomach or diarrhea, he or she cannot be accepted into the school until
well. In the event my child has a communicable disease, a release form from a medical
source may be required before my child re-enters the center. Brilliance Pre-School and
Academy will notify parents if a communicable disease has been introduced into the
school.
I understand that all shot records/immunizations must be current and kept up to date. The
only exemption would be for medical or religious reasons and in those cases we would
need a letter from a physician or clergy. Any child out of compliance will not be allowed to
attend.
I understand that hearing and vision testing is required at age 4 years old. Please make
arrangements with your family’s medical team. If preferred, we will have a service provider
come to school and provide this service to you at an additional cost.
I understand that in the case of a disaster or other even that requires evacuation of the
building, you will be contacted as soon as possible. In the event of evacuation we will go
to the closest safest place.
I give my consent for my child to participate in field trips and water activities (Yes / No ).
I understand the Brilliance Pre-School and Academy does not provide transportation to or
from home or local schools. The only transportation provided will be for pre-approved field
trips.
I understand that Brilliance operates on an open door policy and parents are welcome to
observe, visit, or participate in their child’s class at anytime without notice. If a parent is
going to be a regular visitor, we will require a background check and finger printing.
I understand that I have the right to review a copy of the Minimum Standards, Brilliance
policies as well as the school’s most recent Licensing Inspection Report.
If I have not picked up my child by 6:00 p.m. and all attempts to contact me and all of my
emergency contacts fail, Brilliance Pre-School and Academy will contact Police and State
Agents. (There will be a charge of $1.00 per minute up to $20.00 per hour paid directly to
the person who is waiting with your child
I give my consent for my child’s photo and or video footage to be taken within the school.
I understand that I may not physically discipline my child on school premises.
I understand that any complaints can be discussed with the Director or Assistant Director.
As a parent of Brilliance your opinion is respected and appreciated.
BRILLIANCE PRESCHOOL AND ACADEMY’S STATEMENT OF NON-DISCRIMINATORY POLICY
Brilliance Pre-school and Academy admits students of any race, color, nationality or ethnic origin
for all the rights, privileges, programs, and activities generally accorded or made available to
students at the school. It does not discriminate on the basis of race, color, national or ethnic
origin in dministration of its educational policies, scholarship and loan programs, and athletic
and other school-administered programs.
I understand all of the above and agree to abide by all policies and procedures of Brilliance
Pre-school and Academy as outlined in this agreement. Failure to adhere to these policies
may result in dismissal of my children from the Brilliance.
