General Information

OPERATION NAME:

Circle C Child Development Center

EXECUTIVE DIRECTOR’S NAME:

Michelle Moran

Select Your Campus:*

CDC-West 5917 La Crosse Avenue, Austin, TX 78739

CDC-East (NEW Campus) 5915 La Crosse Avenue, Austin TX 78739

CHILD'S INFO:

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STUDENT INFO:

Child's Name*

First Last Last

Child's Nickname

Nickname

Gender

Boy

Girl

Child's Birth Date*

Child's Address*

Street Address City State / Province / Region ZIP / Postal Code

Age as of Sept 1, 2022*

Date of Admission*

8/15/2022 * CDC First Day of School

Other. Please list below

Date of Admission

PARENT #1 INFO:

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PARENT #1 INFO:

Parent's #1 Name*

First Last

Parent #1 Address*

Same as Child

Other

Parent # 1 Address*

Street Address City State / Province / Region ZIP / Postal Code

Parent #1 Home Phone*

Parent #1 Cell Phone*

Parent #1 Work Phone*

Parent #1 Employer*

Parent #1 Occupation*

Parent #1 Email*

PARENT #2 INFO:

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PARENT #2 INFO:

Is Parent #2's info available?:*

Yes

N/A

Parent's #2 Name*

First Last

Parent #2 Address*

Same as Child

Other

Parent # 2 Address*

Street Address City State / Province / Region ZIP / Postal Code

Parent #2 Home Phone*

Parent #2 Cell Phone*

Parent #2 Work Phone*

Parent #2 Employer*

Parent #2 Occupation*

Parent #2 Email*

Program and Payment

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PROGRAM & PAYMENT:

SELECT YOUR PROGRAM:*

Full-Time Program (Infants-Pre-K) $1500 per month

Part-Time Pre-K Program TTH $450

Part-Time Pre-K Program MWF $550

A $200, new student registration fee is due at your time of registration. Monthly tuition is due and payable on the first of each month. Payments will be made using automatic bank withdrawal or credit card automatic withdrawal (additional 3% fee applies for credit card payments.) through our billing platform, PraxiSchool. You will receive an e-mail with instructions on setting up your account.

Pizza Day Sign Up

The Child Development Center offers pizza lunch days once a week as a fundraiser. Pizza days are every Wednesday for children enrolled at CDC-West and every Thursday for children enrolled at CDC-East. Children may have as much cheese pizza as they want, and teachers will provide a sign-up list for families to volunteer to bring healthy side dishes for the classroom. If you opt in for Pizza Days, it will be billed along with your monthly tuition for an additional $20 per month.

Because this is a fundraiser; no refunds will be given on the balance when the child withdraws. Pizza days will start on September 7th for the 2022-23 school year. If you choose to cancel, you must cancel by the 25th of the preceding month. To cancel, e-mail jelegonye@circleccdc.org

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Yes! Please sign up my child for pizza days. I understand that I will be billed the monthly pizza charge starting September 1, 2022.

No, I would not like to participate in pizza lunch days at this time.

Alternate & Emergency Contacts

Give the name, address and phone number of person (not either parent) to call in case of emergency if parent or guardian cannot be reached. Emergency contact must reside in the same city and state as the child you are enrolling.

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Pizza Days

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EMERGENCY CONTACT:

Emergency Contact Name*

Relationship to child*

Emergency Contact's Phone:*

Emergency Contact's Address*

Street Address City State / Province / Region ZIP / Postal Code

Persons authorized to pick up my child.

Children will only be released to a parent or a person designated by the parent after verification of ID. Please list who is authorized to pick up your child, other than child’s parent(s).

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PERSONS AUTHORIZED TO PICK-UP MY CHILD:

Authorized Person #1 Name*

Authorized Person #1 Phone*

Relationship to child*

Authorized Person #2 Name

Authorized Person #2 Phone

Relationship to child

Authorized Person #3 Name

Authorized Person #3 Phone

Relationship to child

Permissions

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PERMISSIONS:

1. TRANSPORTATION

The CDC does not transport children.

2. FIELD TRIPS:*

I give consent

I do not give consent

for my child to participate in Field Trips. Please Note: Your child’s teacher will provide detailed field trip information prior to any field trip.

3. WATER ACTIVITIES*

I give consent

I do not give consent

for my child to participate in the following water activities: Sprinklers and Water Tables.

4. SNACK TIMES*

A.M. snack

P.M. snack

I understand that the above snacks will be served to my child while in school.

5. DAYS AND TIME

Full Time M-F from: 7:00am to 6:00pm

TTH from 9:00am to 1:30pm

MWF rom 9:00am to 1:30pm

My child is normally in school on the above days and times

6. E-MAIL NOTIFICATIONS*

I give consent

I do not give consent

to be added to Constant Contact, our email notification system.

7. PHOTOGRAPH AND VIDEO*

I give consent

I do not give consent

for the CDC to photograph or video my child for any school related use, including but not limited to promotions and website/social media photos. *We will request separate permission prior to publishing any photos or videos of your child.

PERMISSIONS SIGNATURE OF PARENT OR LEGAL GUARDIAN #1*

PERMISSIONS SIGNATURE OF PARENT OR LEGAL GUARDIAN #2*

Emergency Medical Attention

Authorization

In the event I cannot be reached to make arrangements for emergency medical care, I authorize the person in charge to take my child to:

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EMERGENCY MEDICAL ATTENTION:

Emergency Medical Care & Consent

Name of Emergency Medical Care Facility*

Dell Childrens Hospital, 4900 Mueller Blvd, Austin TX 78723 512-324-0000

Ascension Seton Southwest, 7900 Farm to Market Rd 1826, Austin TX 78737 512-324-9000

St. David's South Austin Medical Center, 901 W Ben White Blvd, Austin TX 78704 512-447-2211

Seton Medical Center, 1201 W 38th St, Austin TX 78705 512-324-1000

Other. Please provide information below.

Name of EMERGENCY Medical Care FACILITY*

Emergency Medical Care Phone*

Emergency Medical Care Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Physician Name*

Physician Phone*

Physician Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Medical Care Consent*

I give consent for the facility to secure any and all necessary emergency medical care for my child.

I do not consent. Affidavit to be submitted. Medical diagnosis and treatment conflict with the tenets and practices of a recognized religious organization, which I adhere to or am a member of, I will submit a signed and dated affidavit stating this, prior to my child's first day of attendance.

MEDICAL CONSENT SIGNATURE OF PARENT OR LEGAL GUARDIAN*

Allergy and Existing Conditions Information

List any special problems that your child may have, such as allergies, existing illness, previous serious illness, injuries and hospitalizations within the last 12 months, any medication prescribed for long-term continuous use, and any other information which CDC personnel should be aware of. If none exist, enter “NA”. .

If your child has a severe allergy, we MUST receive a complete Severe Allergy Form and any required medication, prior to your child's first day of school.

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ALLERGIES & EXISTING CONDITIONS:

List Allergy & Medical Specifics*

ALLERGIES AND EXISTING CONDITIONS SIGNATURE OF PARENT OR LEGAL GUARDIAN*

The Child Development Center operates as a public accommodation under the American with Disabilities Act (ADA), Title III. If you believe that such an operation may be practicing discrimination in violation of Title III, you may call the ADA Information Line at (800) 514-0301 (voice) or (800) 514-0383 (TTY).

Health Insurance

Please provide us with the following information OR check one of the options below:

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HEALTH INSURANCE INFO:

Health Insurance Company:

Policy Number:

Policy Holder’s Name:

Medical Insurance:

I prefer not to provide The Child Development Center with my health insurance information at this time.

My child currently does not have health insurance. I will provide The Child Development Center with this information when it becomes available.

HEALTH INSURANCE SIGNATURE OF PARENT OR LEGAL GUARDIAN*

Enrollment Agreement

The enrollment agreement is between The Child Development Center, Inc. (The “CDC”) and the parent/guardian of the child. Enrollment will continue until terminated in accordance with Section “2” of this Agreement. This Agreement becomes effective upon execution and will continue in effect from the date of execution or until such time that the Child’s enrollment with The CDC.

Please click here to read and download the Enrollment Agreement.

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ENROLLMENT AGREEMENT:

Read Enrollment Agreement*

I agree that I have read and understand the terms of this Enrollment Agreement and agree to abide by its contents.

ENROLLMENT SIGNATURE OF PARENT OR LEGAL GUARDIAN #1*

ENROLLMENT SIGNATURE OF PARENT OR LEGAL GUARDIAN #2*

Additional Documents

Before your child may attend The Child Development Center, the following documents must be submitted.

Immunization Record*

I agree to provide The Child Development Center a copy of my child’s most current immunization record signed by the physician or an official notarized affidavit form developed and issued by the Department of State Health Services prior to my child’s first day of school.

Health Statement*

I agree to submit a health statement (download Health Statement Form) or one provided by my child’s physician, prior to my child's first day of school.

Vision and Hearing Screening

I agree to submit results of a hearing and vision screening (applies to children ages 4 years and older by September 1, 2022).

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PARENT HANDBOOK:

Parent Handbook

Please click here to view or download Parent Handbook and acknowledge receipt below.

I/We acknowledge that I/We have received a copy of Circle C Child Development Center’s Parent Handbook and have been given the opportunity to read the manual and ask questions about and understands the policies contained therein. Furthermore, I/We agree to abide by the policies set forth in the manual. I/We understand that the policies described in the Parent Handbook are not conditions of enrollment, and the language does not create a contract between the Circle C Child Development Center and the parents. Circle C Child Development Center reserves the right to alter, amend, or otherwise modify these guidelines, in its sole discretion, without prior notice. I understand that this form must be signed and dated by all legal guardians before my child may attend any CDC program.

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WRITTEN OPERATIONAL POLICIES*

I acknowledge receipt of the CDC Parent Handbook

HANDBOOK SIGNATURE OF PARENT OR LEGAL GUARDIAN #1*

HANDBOOK SIGNATURE OF PARENT OR LEGAL GUARDIAN #2*

CDC Enrollment

2022-2023 CDC Enrollment Form | New Student

Fields marked with an * are required.

General Information

OPERATION NAME:

EXECUTIVE DIRECTOR’S NAME:

CHILD'S INFO:

STUDENT INFO:

PARENT #1 INFO:

PARENT #1 INFO:

PARENT #2 INFO:

PARENT #2 INFO:

Program and Payment

PROGRAM & PAYMENT:

Pizza Day Sign Up

Alternate & Emergency Contacts

Pizza Days

EMERGENCY CONTACT:

Persons authorized to pick up my child.

PERSONS AUTHORIZED TO PICK-UP MY CHILD:

Permissions

PERMISSIONS:

Emergency Medical Attention

Authorization

EMERGENCY MEDICAL ATTENTION:

Emergency Medical Care & Consent

Allergy and Existing Conditions Information

ALLERGIES & EXISTING CONDITIONS:

Health Insurance

HEALTH INSURANCE INFO:

Enrollment Agreement

ENROLLMENT AGREEMENT:

Additional Documents

PARENT HANDBOOK:

Parent Handbook

2018 Community Report

Contact Info

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CDC Enrollment

2022-2023 CDC Enrollment Form | New Student

Fields marked with an * are required.

General Information

OPERATION NAME:

EXECUTIVE DIRECTOR’S NAME:

CHILD'S INFO:

STUDENT INFO:

PARENT #1 INFO:

PARENT #1 INFO:

PARENT #2 INFO:

PARENT #2 INFO:

Program and Payment

PROGRAM & PAYMENT:

Pizza Day Sign Up

Alternate & Emergency Contacts

Pizza Days

EMERGENCY CONTACT:

Persons authorized to pick up my child.

PERSONS AUTHORIZED TO PICK-UP MY CHILD:

Permissions

PERMISSIONS:

Emergency Medical Attention

Authorization

EMERGENCY MEDICAL ATTENTION:

Emergency Medical Care & Consent

Allergy and Existing Conditions Information

ALLERGIES & EXISTING CONDITIONS:

Health Insurance

HEALTH INSURANCE INFO:

Enrollment Agreement

ENROLLMENT AGREEMENT:

Additional Documents

PARENT HANDBOOK:

Parent Handbook

Footer

2018 Community Report

Contact Info

Be Social!

Sitemap