Enrollment Form — Do Art With Yopp

Creative Learning Studio Application

Please fill out the following.

Parent Email

Student Name

First Name

Last Name

Phone

(###)

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Date of Birth

Student Nickname

Student Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Preferred Hours of Care

Please state your preferred care times between our operating hours of 8:30-5:30. (If your child is participating in Digital Academy and their first class begins before our official start time of 8:30, you may drop off 15 minutes before their first class begins.)

Preferred Days of the Week

Child Lives With:

Custody:

Mother

Father

Both

Other

Mother's Name

Mother's Address

Mother's Employer

Mother's Employer's Address

Mother's Phone

(###)

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Mother's Alt Phone

(###)

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Father's Name

Father's Address

Father's Employer

Father's Employer's Address

Father's Phone

(###)

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Father's Phone 2

(###)

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Medical Information

I hereby grant permission for the staff of this facility to contact the following medical personnel to obtain emergency medical care if warranted. Please submit current physical examination (Form 3040) and immunization record (Form 680 or 681) within 30 days of enrollment.

Doctor 1

Doctor 1 Address

Doctor 1 Phone

(###)

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Doctor 2

Doctor 2 Address

Doctor 2 Phone

(###)

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Dentist

Dentist Address

Dentist Phone

Hospital Preference

Please list allergies, special medical or dietary needs, or other areas of concern:

Emergency Care Plan: Instructions including symptoms, medication, and notification in the event of an actual emergency (if applicable):

Emergency Contacts:

Child will be released only to the custodial parent(s)or legal guardian(s)and the persons listed below. The following people will also be contacted and are authorized to remove the child from the facility in case of illness, accident or emergency, if for some reason the custodial parent(s)or legal guardian(s) cannot be reached.

Emergency Contact 1

Emergency Contact 1 Address

Emergency Contact 1 Phone

(###)

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Emergency Contact 2

Emergency Contact 2 Address

Emergency Contact 2 Phone

(###)

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Emergency Contact 3

Emergency Contact 3 Address

Emergency Contact 3 Phone

(###)

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Helpful Information About Child:

DCF Requirements:

I have received the following documents pertaining to Department of Children and Families. • Sections 7.1 and 7.2, of the Child Care Facility handbook, require a current physical examination (Form 3040) and immunization record (Form 680 or 681) within 30 days of enrollment. • Section 7.3, of the Child Care Facility Handbook, requires that parents receive a copy of the Child Care Facility Brochure, “Know Your Childs Care Facility” (CF/PI 175-24), or • Section 8.3, of the Family Day Care Home/ Large Family Child Care Home Handbook, requires that parent(s) received a copy of the family day care home brochure, “Selecting A Family Day Care Home Provider” (CF/PI 175-28). • Section 7.3, C.3 of the Child Care Family Handbook, requires that parents are provided food and nutrition policies used by the child care facility. • Section 2.8, of the Child Care Facility Handbook, requires that parents are notified in writing of the disciplinary and expulsion policies used by the child care facility, of • Section 2.3, of the Family Day Care Home/Large Family Child Care Home Handbook, requires that parents are notified in writing of the disciplinary and expulsion policies used by the family day care provider.

Your signature below indicates that the information on this enrollment form is complete and accurate.

Appearance Consent and Release:

I hereby grant Yopp, Inc. my unrestricted permission to use photos, video of and quotes from my child created during time with Yopp, Inc. I understand that Yopp, Inc. may use any artistic creation contributed by my child for promotional material. I understand that there will be no payment now or later and that any copyright of the material rests with Yopp, Inc.

Digital Login Release:

To appropriately support the student, I hereby grant permission for the staff to have access to my child’s digital platform login information, as applicable.

Please Sign Below:

All the information is complete and accurate.

Creative Learning Studio Application

New Location coming soon!