Fall 2017-Spring 2018 Childcare Options (check one) Childcare (includes Preschool for ages 3-5) 5 days/week 4 days/week 1-3 days/ week Calvary Baptist Church 2407 Broadway, Yankton, SD 57078 (605) 665-5594 Extended Care for Preschool This form must be returned with a $25 registration fee before enrollment is complete. Registration / Application for Admission CHILD: Last Name First Name Preferred Name/Nickname Male Female Age Date of Birth - - Address City/State/Zip Home Phone Allergies & Other Medical Conditions (asthma, diabetes, epilepsy, physical limitations etc.): Please list any special concerns (behavioral, physical, social, emotional, etc.): Is there any additional information you would like to share about your child? (favorite things, food preferences, special interests, fears, etc.) Previous Child Care Placement(s):
MOTHER: First Name Last Name Address Home Phone Cell Phone E-mail Address Place of Work Work Phone FATHER: First Name Last Name Address Home Phone Cell Phone E-mail Address Place of Work Work Phone Parent s Marital Status Married Separated Divorced Is either parent deceased? Remarried? Custody Arrangements? Is anyone restricted from seeing the child(ren)? If so, please list: EMERGENCY CONTACTS Emergency Contacts: (please list at least 2) Name Relationship to Child Phone Name Relationship to Child Phone Name Relationship to Child Phone PICK UP Please list ALL people authorized to pick up child from center: Name Relationship to Child Vehicle Name Relationship to Child Vehicle Name Relationship to Child Vehicle
HEALTH INFORMATION Child s Doctor: Clinic Phone number Child s Dentist: Phone number *************** ATTACH CHILD S IMMUNIZATION RECORDS PLEASE *************** EMERGENCY MEDICAL CARE AUTHORIZATION I hereby give permission for emergency medical treatment for my child (child s name) if requested by Calvary Kids Club, who is our child care provider. Please note that my child is allergic to the following medications: It is also important to note that my child has the following special medical conditions: Mother/Guardian Signature Date Father/Guardian Signature Date
MEDICATION AUTHORIZATION FORM Child s Name Date Name of medication to be administered Dosage Time to be given Dates to be given: From to Parent Signature Date Date Administered Time Administered Signature of Caregiver Administering Medication Witness Signature Note: Use a separate sheet for each medication to be administered.
CALVARY BAPTIST STATEMENT OF FAITH The Word of God: We believe that the Bible is the Word of God fully inspired and without error in the original manuscripts, written under the inspiration of the Holy Spirit, and that it has supreme authority in all matters of faith and conduct. The Trinity: We believe that there is one living and true God, eternally existing in three persons, that these are equal in every divine perfection, and that they execute distinct but harmonious offices in the work of creation, providence and redemption. God the Father: We believe in God the Father, an infinite, personal spirit, perfect in holiness, wisdom, power and love. We believe that He concerns Himself mercifully in the affairs of all people, that He hears and answers prayer, and that He saves from sin and death all who come to Him through Jesus Christ. Jesus Christ: We believe in Jesus Christ, God's only begotten Son, conceived by the Holy Spirit. We believe in His virgin birth, sinless life, miracles and teachings. We believe in His substitutionary atoning death, bodily resurrection, ascension into heaven, perpetual intercession for His people, and personal visible return to earth. The Holy Spirit: We believe in the Holy Spirit who came forth from the Father and Son to convict the world of sin, righteousness, and judgment, and to regenerate, sanctify, and empower all who believe in Jesus Christ. We believe that the Holy Spirit indwells every believer in Christ, and that He is an abiding helper, teacher and guide. Regeneration: We believe that all people are sinners by nature and by choice and are, therefore, under condemnation. We believe that those who repent of their sins and trust in Jesus Christ as Savior are regenerated by the Holy Spirit. The Church: We believe in the universal church, a living spiritual body of which Christ is the head and all regenerated persons are members. We believe in the local church, consisting of a company of believers in Jesus Christ, baptized on a credible profession of faith, and associated for worship, work and fellowship. We believe that God has laid upon the members of the local church the primary task of giving the gospel of Jesus Christ to a lost world. Christian Conduct: We believe that Christians should live for the glory of God and the well-being of others; that their conduct should be blameless before the world; that they should be faithful stewards of their possessions; and that they should seek to realize for themselves and others the full stature of maturity in Christ. The Ordinances: We believe that the Lord Jesus Christ has committed two ordinances to the local church: baptism and the Lord's Supper. We believe that Christian baptism is the immersion of a believer in water into the name of the triune God. We believe that the Lord's Supper was instituted by Christ for commemoration of His death. We believe that these two ordinances should be observed and administered until the return of the Lord Jesus Christ. Religious Liberty: We believe that every human being has direct relations with God, and is responsible to God alone in all matters of faith; that each church is independent and must be free from interference by any ecclesiastical or political authority; that therefore, Church and State must be kept separate as having different functions, each fulfilling its duties free from dictation or patronage of the other. Church Cooperation: We believe that local churches can best promote the cause of Jesus Christ by cooperation with one another in a denominational organization. Such an organization, whether it is the Conference or a district conference, exists and functions by the will of the churches. Cooperation in a conference is voluntary and may be terminated at any time. Churches may likewise cooperate with interdenominational fellowships on a voluntary independent basis. The Last Things: We believe in the personal and visible return of the Lord Jesus Christ to earth and the establishment of His kingdom. We believe in the resurrection of the body, the final judgment, the eternal felicity of the righteous, and the endless suffering of the wicked.
The following agreement is made between Please check one: Parent / Guardian Child Care Agreement Fall 2017- Spring 2018 Mother/Guardian Father/Guardian and Calvary Kids Club for the care of (child s name). 5 days per week; ages 3-5 (includes PS class) - $135/week. Under 3 yrs - $150/week. 4 days per week: ages 3-5 (includes PS class) - $115/week. Under 3 yrs - $125/week 1-3 days per week: ages 3-5 (includes PS class) - $30/day. Under 3 yrs - $34/day Preschool Extended Care: Preschool Tuition + $5/day. Care will be provided from 6:00 a.m. to 6:00 p.m. Monday through Friday except for holidays. Registration fee is $25. Pre-payment is due on a weekly basis on each THURSDAY for the upcoming week. Families will be billed an extra $25 (per each time) if child is picked up after 6:15 p.m. There will be a $40 change for any checks returned NSF. I have read and understand the Handbook and agree to follow the policies of Calvary Kids Club. I understand and agree to the conditions of this contract agreement. I authorize Calvary Baptist Church and Calvary Kids Club to take our child on field trips and to use our child s image in any promotional material, media releases, Calvary Baptist Church s website or Calvary Facebook page, or for any other lawful purpose. In the event of a medical emergency, I authorize Calvary Baptist Church and Calvary Kids Club to have our child transported to an area hospital by ambulance if deemed necessary by church and/or childcare personnel and EMT personnel. I attest that the information listed on this application is as accurate and complete as possible. Mother/Guardian Signature Date Father/Guardian Signature Date OFFICE USE ONLY: Received on by Amount Paid _$ Cash Check Number