CARE PROGRAM REGISTRATION FORM

TO REGISTER FOR CARE, $50 REGISTRATION FEE PER CHILD, 1ST MONTH’S FEE (cash, check or money order) PER CHILD AND COMPLETED FORM IS REQUIRED. MAIL to CARE PROGRAM Little Rock School District 4800 W. 26th Little Rock, AR 72204 OR BRING to the CARE Office 4800 West 26thRoom 12 Office Hours: 8:00-5:00 M-F/ Phone 447-1880 CARE Site Hours: 7:00 am – 8:00 am and 2:15 pm – 5:30 pm Child care fees are due on the 15th for the upcoming month of service (example: Oct. payment due Sept. 15th)

Child Care Fees

Registration Fee is $60 per child*

Full time 5 days - $210 MonthlyPart time 4 days - $172 MonthlyPart time 3 days - $128 MonthlyPart time 2 days - $85 MonthlyPart time 1 day - $42 Monthly3 Day drop in - $36.00/per cardHoliday (Reservation Only) - $25/Day

CHILD INFORMATION

Child's Name*

School*

Date of Birth

Date

Sex*

Race*

Grade*

Date to Enter*

MOTHER INFORMATION

Mother's Name

Work Phone

Please enter a valid phone number.

Cell Phone

Please enter a valid phone number.

Address - NA if does not apply*

Apartment Number

City/Zip Code

Work Hours

FATHER INFORMATION

Father's Name

Work Phone

Please enter a valid phone number.

Cell Phone

Please enter a valid phone number.

Address - NA if does not apply*

Apartment Number

City/Zip Code

Work Hours

EMERGENCY CONTACT 1 - Other than parent or Guardian

Name*

Address*

Work Phone

Please enter a valid phone number.

Cell Phone*

Please enter a valid phone number.

EMEGENCY CONTACT 2 - Other than parent or Guardian

Name*

Address*

Home Phone

Please enter a valid phone number.

Work Phone

Please enter a valid phone number.

Cell Phone*

Please enter a valid phone number.

REQUIRED INFORMATION

List of Persons Authorized to Pick up Child including parent/guardian - Three names are required*

Child's Doctor*

Address*

Phone Number*

Please enter a valid phone number.

Hospital Preference*

Hospital Phone Number*

Please enter a valid phone number.

Describe medical, physical or mental conditions and/or behavioral problems the CARE staff should know about your child, including allergies

I give permission for use of suntan lotion/sunscreen according to DCCECE Licensing Requirements*

YesNo

In case of emergency, I authorize the CARE Program to arrange for medical/dental care and transportation to the hospital or doctor of my choice or the hospital nearest to the school. CARE cannot assume financial liability for injuries. Student accident insurance is available through the school office. I accept responsibility for paying child care fees by the 15th for the upcoming month of service. If payment is not received by the last working day of the month, a $25.00 late fee will be charged on the first. Nonpayment will result in a drop notice and could result in loss of day care services if the CARE office is not contacted upon your receipt of a drop notice. Children may be interviewed by a DHS licensing specialist to determine compliance with licensing requirements and/or CARE Program staff members or law enforcement agencies if determined to be necessary. Parents have access to their child anytime during the hours of operation (7am-8am/2:15pm-5:30pm).

Date*

Date

Parent or Guardian Filling out this form*

Signature*

Email Address

example@example.com

By checking this box I acknowledge that the registration fee, first month's tuition and a completed registration form must be received by CARE before your child can be enrolled. Feel free to contact the CARE office for verification of receipt of all requested items at 501-447-1880*

I have complied with all requirements above

There is a late pickup fee of $1.00 per minute after 5:30*

I understand

CARE Program
Student Conduct Expectations and Discipline Plan

You are required to read and approve this Discipline Plan
by signature below:

During CARE, children are expected to be responsible for their own behavior by following behavior rules and respecting the rights and property of others.

Behavior rules for CARE children

Follow directions of CARE aides.
No cursing, teasing, threatening or bullying, hitting, fighting, kicking, biting, etc.
Show respect to others and respect the rights and property of all students.
Return all materials to their proper place.
Keep hands, feet and objects to self.
Children must stay in assigned CARE area.
Terroristic threatening will be reported to proper authorities.
Threatening bodily injury will not be tolerated and could result in dismissal.

Consequences

Behaviors that will not be tolerated include extreme disobedience, biting, kicking, fighting, showing signs of aggression, rude and defiant behavior, bullying and threatening and any other inappropriate behavior. When children misbehave, consequences may include the following and can occur at anytime, not necessarily in this order, depending on the severity of the misbehavior. For most minor or non-threatening behavior, warnings and time out from activities will be used to encourage a child to calm down and reflect on his/her behavior. Additional consequences will be used for more severe misbehavior.

Warning.
Time out/ Loss of recreational or play privilege.
Behavior documents.
Parent conference with site staff.
Parent conference with a CARE supervisor in person or by telephone.
Child will be sent home. Parents will be called at the time of the misbehavior and asked to pick up the child immediately.
Short term suspension, 1-3 days. Refunds will not be given for these days.
Long term suspension 1-5 or 1-10 days. Refunds will not be given for these days.
Expulsion from Program.

Note: Corporal punishment (paddling) will not be used in disciplining children in the CARE Program.

Parental help will be requested for behavior problems that cannot be solved by time-out. We reserve the right to suspend a child for 1 to 10 days or expel a child permanently from the program, after appropriate efforts to correct the behavior problems have been made and the child is still unable to conform to the required behavior.

Severe Clause: Immediate suspension or expulsion from the CARE program may occur at any time a student threatens violence, is involved in fighting, causes physical injury or bullies other children, is severely disruptive or endangers the safety of others or any other behavior considered inappropriate. Additional similar behaviors include but are not limited to aggression, rude and defiant behavior, temper tantrums, and biting. The student will be immediately suspended or expelled from the CARE Program, pending a parent conference. Bullying, threatening violent acts, disruptive and or violent behavior will not be tolerated. *In extreme circumstances, it may be necessary to inform the Department of Human Services, Little Rock School District Safety and Security and the Little Rock Police.

Please sign below to confirm you have read and understand the CARE Program Student Conduct Expectations and Discipline Plan

Signature*

Date*

Date

CARE PROGRAM REGISTRATION FORM

ALL INFORMATION MUST BE COMPLETED PER DHS GUIDELINES