Seedlings Owl Day / Enrollment - Sunflower Creative Arts

Seedlings Enrollment Form for the 2019-2020 School Year

Parent One First Name

Parent One Last Name

Parent One Email

Parent One Phone

Parent One Occupation

If stay at home parent please list prior occupation

Parent One Employer

If stay at home parent please list prior employer

Is Parent One a current or former member of the US armed services?

Are you the sole custodian and/or are separated from Parent Two?

No second parent/guardian

Please only use this option if there is NO second parent or legal guardian in the child's life.

We are required to have up to date mailing and physical addresses and contact information for ALL parents and legal guardians at all times.

If there are any changes they must be reported to the Sunflower office within one week.

Parent Two First Name

Parent Two Last Name

Parent Two Email

Parent Two Phone

Parent Two Occupation

If stay at home parent please list prior occupation

Parent Two Employer

If stay at home parent please list prior employer

Is Parent Two a current or former member of the US armed services?

Parent Two Address

Parent Two has a different physical address then parent one.

Parent Two has the same physical address as parent one.

Primary Address:

Address 1

Address 2

City

State

Zip code

Child's First Name

Child's Last Name

Name child goes by (given or nickname)

Child's Birth Date

Placement

I accept the placement I have been offered for my child through the email I received from Sunflower.

I accept the placement I have been offered for my child BUT I would also like to be placed on the waitlist for the following session or combo of sessions.

I accept PART of the placement offered. Please indicate which of the sessions you were offered placement in you would like to accept.

I decline the placement, but I would like to be placed on the waitlist for the following session or combo of sessions.

I decline the placement offered to above child and don’t want to be waitlisted for any sessions.

You will receive an email confirmation if you do not receive one please contact us
email: [email protected] - phone: 561 501-6615

Seedling’s Physician:

Practice:

Phone:

May we call another physician if unable to contact the above?

Yes

No

Persons permitted to remove Seedling from facility:

Parent One / Guardian

Yes No

Parent Two / Guardian

Yes No

If there are any restrictions preventing either parent from picking up/legal custody, please provide legal paperwork with those details to the office as soon as possible.

Who will be fulfilling your family's helper shift duties?

You may have multiple family members (and nannies or babysitters) do helper shifts as long as each of these people:

1. Has completed the helper training
2. Has current CPR and first aid certification*
3. Has submitted an FDLE background check
4. Has completed all required paperwork
5. Completes "Parenting Safe Children" workshop within first year

*Your tuition includes one adult attending one of our upcoming CPR and First Aid trainings

Helper one name:

Helper one phone:

Helper one email:

Helper one relationship to Seedling?

Helper two name:

Helper two phone:

Helper two email:

Helper two relationship to Seedling?

I will have a third, fourth, fifth... person doing helper shifts (I need lots of forms)

Given our limited parking resources, please provide the following information for any cars that will be involved in pick up, drop off or helper shifts: Make, Model, Color, License Plate.

Please let us know right away if there are changes to the cars used.

Car 1: Make

Car 1: Model

Car 1: Color

Car 1: License Plate #

Car 2: Make

Car 2: Model

Car 2: Color

Car 2: License Plate #

Car 3: Make

Car 3: Model

Car 3: Color

Car 3: License Plate #

Car 4: Make

Car 4: Model

Car 4: Color

Car 4: License Plate #

Emergency Contacts

(NOT A PARENT/GUARDIAN) Persons to be contacted in case of illness, accident or emergency, if for some reason the parents or guardians cannot be reached, and authorized to remove the child from the facility.

Emergency contacts cannot be either Parent One or Two, and should be someone within driving distance of Sunflower.

Emergency Contact One NAME

(Other than parents)

Phone

Relationship

Emergency Contact Two NAME

(Other than parents)

Phone

Relationship

Other persons authorized by the parents or guardians to take the child from the facility (if different from above).

Authorized to Pickup One NAME

(Other than parents)

Phone

Relationship

Authorized to Pickup Two NAME

(Other than parents)

Phone

Relationship

Please help us get to know your family better by providing the following details. Thank you

First Name of sibling number one

younger or older sibling of child you are enrolling

Birth Date of sibling number one

First Name of sibling number two

younger or older sibling of child you are enrolling

Birth Date of sibling number two

First Name of sibling number three

younger or older sibling of child you are enrolling

Birth Date of sibling number three

Is there anyone else that you haven't already listed above who is important to your child that we should know about?

May we share your contact info (emails and phone numbers) with other current Seedlings families?

Yes No

Special Instructions regarding eating habits, toileting or areas of concern:

Dietary Preferences:

Seedlings Permissions

Permission for Food-related Activities & Special Occasion Food Consumption
Pursuant to 65C-22.005(1)(c)2., F.A.C., licensed child care facilities must obtain written permission from parents/guardians regarding a child’s participation in food related activities. These activities include such things as: classroom cooking projects, gardening, school wide celebrations, and birthdays.

I

give/decline permission for my child,

to participate in food related activities and special occasions wherein food is consumed, subject to the conditions indicated below.

Permission Options: (Select one of the options below)

My child DOES NOT HAVE a food allergy or dietary restriction. He or she may participate in activities.

My child DOES NOT HAVE a food allergy or dietary restriction. He or she may not participate in activities.

My child HAS a food allergy or dietary restriction. He or she may not participate in activities.

My child HAS a food allergy or dietary restriction. He or she may participate in activities, but must not eat or handle the following items (please list below):

Permission for Application of Topical Lotions, Sprays and Ointments

I

give permission for Sunflower Creative Arts Staff to apply the following to my child

Sunscreen

Yes

No

Insect repellant

Yes

No

Sting Stop

Yes

No

What is Sting Stop?

Topical Arnica

Yes

No

What is Arnica?

Permission for Administration of Oral Arnica and Benadryl

I

give permission for Sunflower Creative Arts Staff to administer the following to my child,

Oral Arnica

Yes

No

What is Arnica?

Liquid Benadryl

Yes

No

Syrup of Ipicac

Yes

No

What is Syrup of Ipicac?

I have received and read the Emergency Response Plan.

I understand that Sunflower Creative Arts is a NUT-FREE environment. No nuts, nut products or nut oils are allowed in the facility, including any and all food that I provide and send with my child.

I understand that Sunflower Creative Arts is a non-smoking environment.

ARTICLE XV, B, 7, A, PBC Rules requires that parents must receive a copy of the Child Care Facility Brochure, KNOW YOUR CHILD’S DAY CARE CENTER. I have received a copy of the Child Care Facility Brochure, KNOW YOUR CHILD’S DAY CARE CENTER.

ARTICLE IV, C, 5, PBC Rules requires that parents be notified in writing of the disciplinary practices used by the child care facility. I have received in writing the disciplinary practices used by this child care facility.

ARTICLE XIII, B, 1, PBC Rules requires the parents complete an AUTHORIZATION FOR EMERGENCY MEDICAL CARE in the event of serious illness or accident and if the parents cannot be reached. I authorize the child care center to obtain emergency medical care for my child.

During the 2009 legislative session, a new law was passed that requires child care facilities, family day care homes and large family child care homes provide parents with information detailing the causes, symptoms, and transmission of the influenza virus (the flu) every year during August and September. I have received the brochure on Influenza Virus, The Flu, A Guide to Parents.

Required by the Palm Beach County Health Department

ALTERNATE NUTRITION PLAN AGREEMENT

ARTICLE XII, B, PBC Rules require the parent and the center complete an ALTERNATE NUTRITION PLAN AGREEMENT if the meals or snacks are furnished by the child’s parent.

SEEDLING FULL NAME:

ALTERNATE NUTRITION PLAN AGREEMENT:

Indicate Special Dietary Requirements:

I understand and approve the use of the Alternate Nutrition Plan.

I agree to provide the parent with a suggested meal pattern and menus and to discuss any problems which might develop in the use of the Alternate Nutrition Plan.

Parent One Name

Parent Two Name

Additional Program Acceptance Requirements
In order to be accepted into the Seedlings program, parents must fulfill the Enrollment Requirements, plus:

One parent or guardian must attend CPR and first aid training, which will be provided at Sunflower. The cost for one parent is included in your fees. We encourage both parents to take advantage of this opportunity to learn valuable lifesaving skills. The cost for a second parent or guardian is $50.

Both parents or guardians must attend training on the prevention of child abuse.

Sunflower offers Parenting Safe Children Workshops twice a year. Please check with the office to find out the date of the next workshop.

Complete Medical forms (State of Florida School Entry Health Exam and Florida Certification of Immunization).

Complete Background Check paperwork.

Enrollment Policy

Seedlings is a unique educational program stemming from specific philosophy and a core set of beliefs about child development and the social, emotional and environmental needs of young children. For Seedlings to be effective, both parents (or guardians) must be supportive of the methods and goals of the program.
Consequently Sunflower Creative Arts reserves the right to refuse admission to any family that we believe is not truly supportive of our model. While this decision is always hard we firmly believe that it is in the best interest of the child, the family, and the health of Sunflower’s programing.

Sunflower Creative Arts Photo/Video Release

I/We hereby give to Sunflower Creative Arts, and any of its associated or affiliated companies, their directors, officers, agents, employees and customers, and appointed advertising agencies, their directors, officers, agents and employees, the right to reproduce in any of its printed and online publications (such as newsletters, annual reports, websites, social media posts and blog posts), as well as any media that has yet to be created, all pictures, audio and video that it has produced of myself and/or my child(ren).

I/we authorize Sunflower Creative Arts to use all such pictures, audio and video and duplicates thereof, in perpetuity, for its publicity purposes and dispose of them as they may see fit. I/we hereby release Sunflower Creative Arts, from all claims of every kind on account of such use.

Electronic Signature Agreement. By selecting the "I Accept" button, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement. By selecting "I Accept" you consent to be legally bound by this Agreement's terms and conditions. You further agree that your use of a key pad, mouse or other device to select the "I Accept" button constitutes your signature acceptance and agreement as if actually signed by you in writing.

Please contact the Sunflower office if you have any questions • 561 501-6615.

Photo/Video Release

I accept

I do NOT accept

Sunflower Creative Arts Release and Waiver of Liability

“Sunflower” means Sunflower Creative Arts, Inc., a Florida not-for-profit corporation, its officers, directors, volunteers, employees, representatives, agents and assigns. “Sunflower Activities” means any and all events, classes, programs, and/or services, formal and informal, offered and/or provided by Sunflower.

In consideration of participation in any Sunflower Activities, you, as a parent or guardian, on behalf of yourself and your child/children, waive, release and forever discharge any and all rights and claims for injuries, damages, losses, demands, recoveries, suits, payments, actions, and judgments of every nature and description, against Sunflower for injuries sustained or suffered by you and/or your child/children during any Sunflower Activities.

You hereby agree to hold Sunflower harmless and faultless for any harms or injuries that arise out of or are in any way related to Sunflower Activities and/or your participation and/or your child’s/children’s participation in Sunflower Activities, even if arising from the actions, acts of omission, negligence and/or gross negligence of Sunflower.

You on behalf of yourself and/or your child/children hereby knowingly and freely assume any and all risks of injury, known or unknown, from participating in any Sunflower Activities including but not limited to: physical injury, psychological or emotional injury, paralysis, or death.

You hereby certify that you are legally capable and competent to understand and execute this release and waiver of liability agreement without coercion on behalf of yourself and/or your child/children.

You hereby represent that you and/or any child or children in your care who will participate in any Sunflower Activities are physically, mentally and emotionally fit to participate in Sunflower Activities.

You hereby certify that you have read and fully understand this release and waiver of liability agreement and you understand that you are giving up important rights for yourself and/or your child/children.

You are free to agree or not agree to this agreement by choosing not to participate and/or to not permit your child/children to participate in Sunflower Activities. You have the right to discuss this agreement with Sunflower prior to participation.

You and/or your child/children, by participating in Sunflower Activities, consent to and grant Sunflower Creative Arts, Inc. license to use your and/or your child’s/children’s likeness(s), voice(s), and/or name(s), without compensation, for use in any and all media, whether now known or hereafter devised, in perpetuity, and you release Sunflower Creative Arts, Inc., its successors, assigns and licensees from any and all liability in relation to all of said uses.

You agree to follow and adhere to all Sunflower rules and understand and agree that you may be asked to leave at any moment and for any reason without any effect to the validity of this agreement.

You understand and agree that your and/or your child’s/children’s participation in Sunflower Activities indicates that you hereby waive your rights and/or the rights of your child/children to sue or bring other legal action against Sunflower as stated above and to hold Sunflower harmless as stated above.

Electronic Signature Agreement. By selecting the "I Accept" button, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement. By selecting "I Accept" you consent to be legally bound by this Agreement's terms and conditions. You further agree that your use of a key pad, mouse or other device to select the "I Accept" button constitutes your signature acceptance and agreement as if actually signed by you in writing.

Waiver

I Accept

Parent One Signature

Parent Two Signature

Your enrollment will not be final until we have received the non-refundable $200 family enrollment fee.

Please allow 10 to 60 seconds for the form to transmit after you click the submit button.

Your enrollment form has not been received until you have been redirected to the next page.

You will receive an email confirmation if you do not receive one please contact us
email: [email protected] - phone: 561 501-6615