TWICE AS NICE CHILD CARE CENTER



TWICE AS NICE PRESCHOOL

792 Valley Road, Middletown, RI 02842

Phone: (401) 841-5357 Fax: (401) 848-7521

Email: andreaf@

APPLICATION FORM 2021-2022

Child’s Information

|Child’s Last Name |Child’s First Name |Nickname |

|Date of Birth |Gender |Program (circle one) |

| |M F |Toddler/Preschool/Pre-K |

|Street Address |City/Town |State/Zip Code |

Parent/Guardian Information

|Parent/Guardian #1 Name |Home Phone |Cell Phone |

|Street Address |City/Town |State/Zip Code |

|Email Address |Employer |Employer Phone |

|Parent/Guardian #2 Name |Home Phone |Cell Phone |

|Street Address |City/Town |State/Zip Code |

|Email Address |Employer |Employer Phone |

|Parents’ Marital Status |Are there any active court orders related to the child’s custody or release? |

|Married | |

|Separated |Yes |

|Divorced |No |

|Widowed | |

|Single |If yes, a copy MUST be provided prior to the start of the program. |

Enrollment Information (Please circle the program your child will attend)

| | |

|Full Day (7am-5:30pm) |Toddler (7am-5:30pm) |

|2 3 5 Days |2 3 5 Days |

|Please check one: |Please indicate start date: |

|School Year (9/7/21-6/17/22) | |

| | |

|Year Round Program | |

I am a:

|Family/Single Parent YMCA Member |Non-Member |

TWICE AS NICE PRESCHOOL

Newport County YMCA

792 Valley Road, Middletown, RI 02842

(401)841-5357

FINANCIAL AGREEMENT

I agree to pay Twice As Nice the following tuition for my child’s enrollment:

Registration fee in the amount of $60.00 and 1 week payment $________ (due at the time of registration).

Tuition $________ per week is due weekly and must remain paid 2 weeks in advance at all time.

Tuition is considered late if it is received after the due date on the payment calendar. A $20.00 late fee will be assessed, per late payment. Payments must be kept up to date in order to avoid a late fee. Failure to make your payment in a timely manner will result in a warning and could result in dismissal from the program.

A one month written notice is required if your child will be withdrawing from the program.

Late fee pick-up policy is as follows:

• A late fee of $1.00 per minute that you arrive past your scheduled pick-up time will be charged on your account.

• Any parent that continuously picks up their child late will be assessed a $20.00 late pick-up fee for each occurrence.

ALL PAYMENTS ARE FINAL AND NON-REFUNDABLE.

• Please make checks payable to Newport County YMCA.

• DHS # (if applicable):_________________________

Parent Signature _________________________ Date____ /____ /_____

Registration Fee Paid ______ Date ___ /___ /_____

First Tuition Payment Paid ______ Date ___ /___ /_____

TWICE AS NICE PRESCHOOL

Newport County YMCA

792 Valley Road, Middletown, RI 02842

(401)841-5357

Emergency Contact/Authorized for Pick Up

The following people may be contacted if there is an emergency regarding my child and I am unable to be reached. They are also authorized to pick up my child. I understand that these individuals MUST be at least 18 years of age and be able to present a photo ID to sign out my child.

|Name |Emergency Contact? |Relationship to the Child |Phone Number |

| |Yes or No | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

PHOTOGRAPH AUTHORIZATION

o I give Twice As Nice and the Newport County YMCA permission to photograph my child. I understand that these photographs may be displayed at Twice As Nice and my also be used for advertisement purposes.

o No, thank you. Please do not photograph my child.

_________________________________________ ______________________

Parent/Guardian #1 Signature Date

_________________________________________ ______________________

Parent/Guardian #2 Signature Date

Dear Parent/Guardian:

In order for any child to attend school in Rhode Island, it is mandated that a Physician’s Record of Immunization and Pre-admission Examination be provided to school officials.

Please have the attached State of Rhode Island School Physical Form completed by your physician and return it to school.

In addition, please respond to the questions listed below concerning your child. Sign and date this page prior to returning it to school.

Child’s name:__________________________________________

Has your child had a tuberculin skin test? Yes__ No___

If yes: Date:_________ Positive______Negative________

Has your child had a lead screening test? Yes__ No____

If yes: Date:_________ Positive______Negative________

Has your child ever visited a dentist or dental clinic? Yes____No____

Are there any conditions which should be brought to the attention of teachers and/or nurse in school, e.g. allergies, seizures, surgery etc?

Yes___________ No_____________

If yes, please specify: ___________________________________________

_______________________________________________________________________________________________________________________________________________________________________________________

Parent signature:____________________________ Date:______________

Help us get to know your child!

Child’s name: ____________________________________

Has your child gone to preschool or daycare before? Yes No

If so, where?___________________________________________

Please describe previous experience:____________________________________

__________________________________________________________________

__________________________________________________________________

Does your child play well alone? Yes No

Does your child play well in groups? Yes No

Please circle words below that describe your child:

Friendly Aggressive Shy Withdrawn

Dependent Independent Impulsive Fearful

Quiet Sympathetic Attentive Even-tempered

Sleepy Stubborn Happy Clumsy

What makes your child mad or upset? ____________________________________

___________________________________________________________________

___________________________________________________________________

Are there any situations your child finds difficult?____________________________

___________________________________________________________________

___________________________________________________________________

Is your child frightened of anything?______________________________________

How does your child show his/her feelings?_________________________________

What is the best way of handling your child?________________________________

___________________________________________________________________

Does your child have any difficulties in speaking? Yes No

Does your child speak another language? Yes No Specify___________

Has your child ever been separated from either parent for an unusual period of time? Yes No If yes, please explain:______________________________________

____________________________________________________________

Toilet Habits:

Is your child toilet trained? Yes No

Does your child need to be reminded to go to the bathroom? Yes No

Word used for urination:________________ Bowel Movement:________________

Does your child need to go more frequently than usual for his/her age?__________

Does your child have accidents?_________________________________________

Sleeping:

What time does your child go to bed at night?___________Wake up?___________

Does your child nap? Yes No Time?__________to__________

____________________________________________________________

Eating:

Is your child usually hungry at mealtimes?________between meals?______

What foods does your child refuse to eat?__________________________________

What eating problems does your child have?________________________________

Any food allergies or any other allergies?_______________________________

Additional comments:

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Milestones

Has your child learned to:

1. Say nursery rhymes? No Yes

2. Sing songs? No Yes

3. Listen to stories? No Yes

4. Say his or her name? No Yes

5. State his or her age? No Yes

6. Recognize and name common objects? No Yes

7. Follow simple directions? No Yes

8. Can your child count? No Yes How far?____

9. Balance on one foot? No Yes

10. Throw and catch a ball? No Yes

11. Ride a tricycle? No Yes

12. Draw a person? No Yes

13. Write his/her name? No Yes

What do you hope will be included in your child’s preschool program?

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

Parents Signature:____________________________Date:____________

TWICE AS NICE PRESCHOOL

Newport County YMCA

792 Valley Road, Middletown, RI 02842

(401)841-5357

Authorization for Emergency Treatment

I authorize Twice As Nice staff who are trained in the basics of First Aid/CPR to give my child First Aid/CPR when appropriate. In the event of hospital admittance, I hereby authorize the Newport County YMCA to arrange for medical examination and/or treatment of my child, should an emergency arise during program hours. It is also understood that every reasonable effort will be made by the staff to contact me at the emergency numbers I have provided before any medical action is taken.

I understand that the most appropriate hospital will be based upon the needs of my child and at the discretion of the First Responders.

______________________________________________________

Child’s Name

___________________________________ ____________________________

Physician’s Name Physician’s Number

___________________________________ ____________________________

Health Insurance Carrier Policy Number

________________________ __________________ __________________

Signature: Parent/guardian Primary telephone Secondary telephone

________________________ __________________ __________________

Signature: Parent/guardian Primary telephone Secondary telephone

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