enrollment form All parents must fill out our form completely and download the Parent Handbook and Handbook Addendum. - Step 1 of 8THE CHILD TO BE ENROLLEDPlease list the child's information belowChild's Name *FirstLastChild's AddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeChild's Date of BirthDate of EnrollmentChild's Sex *MaleFemaleChild's Social Security NumberChild's RaceBlack/African AmericanAmerican Indian/Alaska NativeNative Hawaiian/Pacific IslanderWhiteHispanic/LatinoNextENROLLING PARENT INFORMATIONPlease list your information belowEnrolling Parents Name *FirstLastEnrolling Parents PhoneEnrolling Parents Relationship to childEnrolling Parents Parents AddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeEnrolling Parents Email *Enrolling Parents EmployerEnrolling Parents Work NumberEnrolling Parents Work AddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeEnrolling Parents Social Security Number Enrolling Parents Driver License NumberNextADDITIONAL PARENTPlease list the additional parents of the childAdditional Parents Name *FirstLastAdditional Parent's Relationship to childAdditional Parent's Address Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeAdditional Parent's PhoneAdditional Parent's Email *Additional Parent's Employer Additional Parent's Work Number Additional Parent's Work AddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeAdditional Parent's Social Security Number Additional Parent's Driver License NumberChild's Primary Residence *MotherFatherBothGuardianMay the non-custodial parent pick up the child? *YesNoParent's Marital Status *MarriedSingleDivorcedIf divorced who has legal custody?NextAUTHORIZED ADULTS THAT MAY PICK UP YOUR CHILDThe child will be released only to the people on this application and the following persons. The following people will also be contacted and are authorized to remove the child from the center in case of illness, accident, or emergency, if for some reason the custodial parent or legal guardian cannot be reached:Authorized Name *FirstLastAuthorized AddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeAuthorized PhoneAuthorized Name 2 *FirstLastAuthorized Address 2Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeAuthorized Phone 2NextDOES YOUR CHILD HAVE ANY SPECIAL NEEDS?My child has the following special needs: The following special accommodation(s) may be required to most effectively meet my child’s needs while at this center: My child is currently is on medication(s) prescribed for long-term continuous use and/or has the following pre-existing illness, allergies, or health concerns: What does your child say when he/she wishes to use the toilet? Is your child potty trained? YesNoCan your child wipe him/herself? YesNoNextEMERGENCY CONTACTSIn the event that we cannot reach the parents, please list the people you would like us to contact. Emergency Contact's Name *FirstLastEmergency Contact's Relationship to childEmergency Contact's PhoneChild’s Physician: *FirstLastPhysician's PhoneMedical facility the child uses: Medical Facility AddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeChild’s allergiesThe child's current prescribed medicationChild’s special medical needs and conditionsMEDICAL EMERGENCYIn the event of an emergency involving my child, and A Step Ahead Learning Center cannot reach me, I hereby authorize any needed emergency care. I further agree to be fully responsible for all medical expenses incurred during treatment of my child.SignatureClear SignatureDateEMERGENCY MEDICAL AUTHORIZATIONShould your child suffer an injury or illness while in the care of A Step Ahead Learning Center and the facility is unable to contact me (us) immediately, A Step Ahead Learning Center shall be authorized to secure such medical attention and care for my child as may be necessary. I (we) shall assume responsibility for payment of services. I (we) agree to keep the facility informed of changes in telephone numbers, etc. where I can be reached. The facility agrees to keep me informed of any incidents requiring professional medical attention involving my child. Child’s primary source of health care isKnown medical condition (e.g. diabetes, asthma, drug allergies) SignatureClear SignatureDateNextPARENTAL AGREEMENTA Step Ahead Learning Center, Inc. agrees to provide child care for your child on Monday through Friday, 6:30 a.m. to 6:30 p.m. from January to December. Times will vary due to staggered arrival and dismissal. Child's Name *FirstLastMy child will participate in the following meal planBreakfastLunchAfternoon SnackADDITIONAL AGREEMENTS2. Before any medication is dispensed to my child, I will provide written authorization, which includes the date, name of the child, name of the medication, prescription number, if any, dosage, date and time medication is to be given. ( We will only give medications at 12:00 p.m.) Medication will be in the original container with my child’s name marked on it. 3. My child will not be allowed to enter or leave the facility without being escorted by an authorized person. 4. I acknowledge it is my responsibility to keep my child’s records current to reflect any significant changes as they occur, (e.g. telephone numbers, work location, emergency contacts, child’s physician, child’s health status, and immunization records. Etc.) 5. A Step Ahead Learning Center agrees to keep me informed of any incidents, including illness, injuries, and adverse reactions to medications, exposure to communicable diseases, which include my child. I agree to inform A Step Ahead Learning Center if my child has been exposed to COVID-19. I also agree to provide my child (3 years and older) with appropriate personal protective equipment. 6. A Step Ahead Learning Center agrees to obtain written authorization from me before my child participates in routine transportation, field trips, special activities away from the facility, and water related activities occurring in water that is more than two feet deep. I understand that all transportation-related activities are suspended until the end of the covid-19 pandemic. 7. I have received a copy of the parent handbook and agree to abide by the policies and procedures for A Step Ahead Learning Center. SignatureClear SignatureDate / TimeNext A Step Ahead Learning Center Photo/Video Release Form A Step Ahead Learning Center includes photos/videos of students, teachers, and school activities on its website and Facebook page. Though the names of faculty, staff, and administration will regularly be used, it is our policy that the full names of students will not. Occasionally, it might be necessary to use the first name of a student, but no last names, addresses, and/or telephone numbers will ever be used. In addition, we are a performing arts center. There will be occasions when we live stream video of performances. As a parent of the student listed below, I hereby consent to the use of photographs/video taken by the school for publicity, promotional or educational purposes (including publications, publication or broadcast via newspapers, internet or other media sources). I do this with full knowledge. I waive, and release ASAL its, owners or employees from, any claims demands or liability in connection with the above. I have read and understand this photo release policy. Photo/Video Release For *FirstLastPhoto/Video Release SignatureClear SignaturePhoto/Video Release Date SignedHOW DID YOU FIND US?How did you hear about A Step Ahead Learning Center? A friend or familyDrive byInternetOtherReferring Responsible Party InformationFirstLastSubmit Parent downloads Parent Handbook Parent Addendum