DIRECTOR’S NAME:

Michelle Moran

CHILD'S INFO:

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STUDENT INFO

SELECT YOUR SCHOOL:*

Child's Name*

First Last Last

Child's Nickname

Nickname

Gender

Boy

Girl

Date of Admission*

Child's Birth Date*

Age as of Sept 1, 2022*

Child's Grade for the 2022-2023 school year*

Pre-K

Kindergarten

First Grade

Second Grade

Third Grade

Fourth Grade

Fifth Grade

Child's Address*

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

PARENT #1 INFO:

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PARENT #1 INFO

Parent #1 Name*

First Last

Parent #1 Address*

Same as Child

New Address

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

New Address

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

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PAYMENT

Payment Options

Select your payment option*

A non-refundable $100 registration fee is required upon registration. Monthly tuition is $340 and is due and payable on the first of each month. Payments must be made using Tuition Express automatic bank withdrawal or Tuition Express credit card automatic withdrawal (additional 3% fee applies).

Download the Tuition Express Form and email the signed copy to mflores@circleccdc.org
or bring a signed copy to the CDC main office at 5917 La Crosse Avenue.

A non-refundable $100 registration fee is required upon registration. Monthly tuition is $300 and is due and payable on the first of each month. Payments must be made using Tuition Express automatic bank withdrawal or Tuition Express credit card automatic withdrawal (additional 3% fee applies).

Download the Tuition Express Form and email the signed copy to mflores@circleccdc.org
or bring a signed copy to The CDC main office at 5917 La Crosse Avenue.

A non-refundable $60 registration fee is required upon registration. Monthly tuition is $250 and is due and payable on the first of each month. Payments must be made using Tuition Express automatic bank withdrawal or Tuition Express credit card automatic withdrawal (additional 3% fee applies).

Download the Tuition Express Form and email the signed copy to mflores@circleccdc.org
or bring a signed copy to the CDC at 5917 La Crosse Avenue.

A non-refundable $60 registration fee is required upon registration. Monthly tuition is $270 and is due and payable on the first of each month. Payments must be made using Tuition Express automatic bank withdrawal or Tuition Express credit card automatic withdrawal (additional 3% fee applies).

Download the Tuition Express Form and email the signed copy to mflores@circleccdc.org
or bring a signed copy to the CDC main office at 5917 La Crosse Avenue.

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. Parents will always be called before the emergency contact. Emergency contact must reside in the same city/state as the child you are enrolling.

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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 Photo 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*

Authorized Person #1 Relationship to Child*

Authorized Person #2 Name

Authorized Person #2 Phone

Authorized Person #2 Relationship to Child

Add additional Authorized Persons

Yes

N/A

Authorized Person #3 Name

Authorized Person #3 Phone

Authorized Person #3 Relationship to Child

Authorized Person #4 Name

Authorized Person #4 Phone

Authorized Person #4 Relationship to child

Permissions

TRANSPORTATION

The CDC does not transport children.

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PERMISSIONS

MEALS:*

P.M. snack

the above meal will be served to my child while in care

DAYS AND TIMES*

Monday-Friday from 3:10pm-6:00pm

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

CONSTANT CONTACT*

I give consent

I do not give consent

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

PHOTOGRAPH AND VIDEO*

I give consent

I do not give consent

for the CDC to photograph or video tape my child for any school related use, including but not limited to news media, promotion and website photos.

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

Physician Name*

Physician Phone*

Physician Address*

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

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

Medical Care Consent*

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

Affidavit

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.

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, please fill out the Severe Allergy Form and return to The CDC main office or email the completed form to Mary Flores: mflores@circleccdc.org

Severe Allergy Forms MUST be updated every 12 months or sooner, if your child's needs change.

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ALLERGIES & EXISTING CONDITIONS

List Allergy & Medical Specifics*

Child daycare operations are public accommodations 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).

Before my child may attend an afterschool program through the Circle C Child Development Center, please confirm the following:

My child’s immunization records are on file at the following school:*

HEALTH RECORDS SIGNATURE OF PARENT OR LEGAL GUARDIAN*

Health Insurance

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

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HEALTH INSURANCE

Health Insurance Company:

Policy Number:

Policy Holder’s Name:

Medical Insurance:

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

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

HEALTH INSURANCE SIGNATURE OF PARENT OR LEGAL GUARDIAN*

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ENROLLMENT AGREEMENT

Enrollment Agreement

The enrollment agreement is between the Circle C Child Development Center, Inc. (the “CDC”) and the parent/guardian of the child. Enrollment will continue until terminated in accordance with Section “D” of this Agreement. This Agreement becomes effective upon execution and will continue in effect until the earlier of one (1) year 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.

Read Enrollment Agreement*

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

ENROLLMENT SIGNATURE OF PARENT OR LEGAL GUARDIAN #1*

ENROLLMENT SIGNATURE OF PARENT OR LEGAL GUARDIAN #2*

2021-2022 Parent Handbook

Please click here to view or download the Afterschool Parent Handbook and acknowledge receipt below. You may request a hard copy from The Child Development Center front office.

I/We acknowledge that I/We have received a copy of The Child Development Center’s After School Parent Handbook and have been given the opportunity to read the handbook and ask questions about and understand the policies contained therein. Furthermore, I/We agree to abide by the policies set forth in the handbook. 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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PARENT HANDBOOK

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WRITTEN OPERATIONAL POLICIES:*

I acknowledge receipt of the afterschool Parent Handbook

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HANDBOOK SIGNATURE OF PARENT OR LEGAL GUARDIAN #1*

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HANDBOOK SIGNATURE OF PARENT OR LEGAL GUARDIAN #2*

2022-2023 Parent Calendar

Please click here to view or download the 2022-2023 Parent Calendar.

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CREW Registration

2022-2023 After School CREW Registration Form

Fields marked with an * are required.

DIRECTOR’S NAME:

CHILD'S INFO:

STUDENT INFO

PARENT #1 INFO:

PARENT #1 INFO

PARENT #2 INFO:

PARENT #2 INFO

PAYMENT

Payment Options

Alternate & Emergency Contacts

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

Before my child may attend an afterschool program through the Circle C Child Development Center, please confirm the following:

Health Insurance

HEALTH INSURANCE

ENROLLMENT AGREEMENT

Enrollment Agreement

2021-2022 Parent Handbook

PARENT HANDBOOK

2022-2023 Parent Calendar

2018 Community Report

Contact Info

Be Social!

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CREW Registration

2022-2023 After School CREW Registration Form

Fields marked with an * are required.

DIRECTOR’S NAME:

CHILD'S INFO:

STUDENT INFO

PARENT #1 INFO:

PARENT #1 INFO

PARENT #2 INFO:

PARENT #2 INFO

PAYMENT

Payment Options

Alternate & Emergency Contacts

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

Before my child may attend an afterschool program through the Circle C Child Development Center, please confirm the following:

Health Insurance

HEALTH INSURANCE

ENROLLMENT AGREEMENT

Enrollment Agreement

2021-2022 Parent Handbook

PARENT HANDBOOK

2022-2023 Parent Calendar

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2018 Community Report

Contact Info

Be Social!

Sitemap