2024/2025 Enrollment Form

Please fill out all required fields.

Child Information

Child's Full Name

Child's Date of Birth

Hair Color

Identifying Marks

Upload File

Child's Nickname

Gender

Male

Female

Primary Language

Eye Color

Ethnicity

Pick Up from School?

Yes

Grade

Indicate times your child will be in care

Parent Information 1

Parent Full Name

Relationship to Child

Street Address

City

Zip code

Primary Phone Number

Primary Email

Work Address

Work City

Work Zip code

Work Phone Number

Work Email

Parent Information 2

Parent Full Name

Relationship to Child

Street Address

City

Zip code

Primary Phone Number

Primary Email

Work Address

Work City

Work Zip code

Work Phone Number

Work Email

Other family members/people living in the household

Full Name

Relationship to child

Full Name

Relationship to child

Do you need an annual tax statment?

Yes

If divorced or separated, please explain custody/visitation arrangements or court orders

The Commonwealth of Massachusetts Department of Early Education and Care Small & Large Group Transportation Plan and Authorization

Authorization for Release/Pickup

ID must be shown for us to release a child.

Parents and family listes above

Contact Full Name

Relationship to child

Emergency Phone Number

Street Address

City

Zip code

Contact Full Name

Relationship to child

Emergency Phone Number

Street Address

City

Zip code

My child needs a booster seat.

Yes

Health Information

Upload File

Attach forms as needed. EX: individual health care plan (IHCP), medication consent forms, doctor signatures.

Health Concerns

Does your child take any medications regularly?

Yes

If yes, what medications?

Does your child have any chronic health concerns? (asthma, seizures, nose bleeds, allergies, etc.)

Yes

Any side effects?

If yes, how often?

First Aid & Emergency Medical Care Consent Form

I authorize staff at the Academic Achievement Center who are trained in the basics of first aid/CPR to give my child first aid/CPR when appropriate.

I understand that every effort will be made to contact me in case of an emergency requiring medical attention for my child. However, if I cannot be reached, I hereby authorize the program to transport my child to the nearest medical care facility and to secure necessary medical treatment for my child.

I give Academic Achievement Center permission to give my child first aid when necessary. I understand my child will be transported to the hospital by ambulance if medically necessary. I hereby authorize the Academic Achievement Center to secure the necessary medical treatment for my child until I arrive at the hospital.

Child Doctor Name

Child Dentist Name

Doctor Phone Number

Dentist Phone Number

I give Academic Achievement Center permission to apply the following products on my child. I understand that products will be used as stated on the label, and my child will be tested for allergies to these products prior to use.

Please check off what products can be used:

Bug Spray

Sun Block SPF 30 (no-ad,equate, CVS, Coppertone)

Hand Sanitizer (if no please provide child with their own hand sanitizer)

Triple Antibiotic Ointment

Personal History/Questionnaire

Illness and or hospitalization?

Yes

If yes, explain?

Any speech difficulties?

Yes

If yes, explain?

Is the child receiving any services? (speech, OT/PT)

Yes

Special physical conditions, disabilities?

Yes

If yes, explain?

Any developments delays or concerns?

Yes

If yes, explain?

If yes, explain and how often?

Social/Emotional Development

Describe your child

How does your child show happiness?

Saddness?

Frustration?

How does your child self-soothe?

What does your child like to do?

Affection?

Anger?

How do you comfort your child?

What are your child's fears? (dark, strangers, animals)

Favorite toy/game?

Does your child have any behavorial issues/concerns? If yes, please explain.

What is your method of discipline at home?

Do you ahve any concerns about the child's social or emotional development?

What would you like your child to gain from their experience at our center?

Any additional information about your child?

Other Permissions

I give the Academic Achievement Center permission to take and display my child's photo for the following:

Center Newsletter

Classroom and Center Display

Local Newspaper

Center Social Media Sites

I give permission for my child to Mason Field and the neighborhood near or around the center for field trips.. I understand that staff will be supervise my child at all times.

Yes

I hereby grant authorization for the Academic Achievement Center to access and receive all pertinentschool documentation, reports, and communication pertaining to my child. I trust that this informationwill be handled with the utmost professionalism and confidentiality.

Yes

Acknowledgements & Agreements

I have received a copy of the Academic Achievement Center’s Parents Handbook and read and understand its contents. I agree to all procedures and conditions set forth therein.

TERMINATION AND SUSPENSION

I have read and understood the termination and suspension policy, which is found on page 1 of the Academic Achievement Center’s Parents Handbook. It states that AAC has the right to terminate any child or family from the program for just cause. I agree to all procedures and conditions set forth therein.

LATE PICK-UP POLICY AND AGREEMENT

I have read and understood the Late Pickup Policy found on page 1 of the Academic Achievement Center’s Parent Handbook. This policy states that any parent whose child is picked up after closing hours will be charged. In signing this form, I am agreeing to this policy and committing to the said pick-up time. I also understand that failure to comply with this policy may result in termination of services.

HOMEWORK HELP POLICY AND AGREEMENT

I acknowledge the following: AAC teachers will assist the students in completing their homework and will spot-check their completed work. AAC does not provide one-on-one homework help as part of the after-school program.

TUITION PAYMENT AGREEMENT
I have read and understood the tuition policy on page 1 of the Academic Achievement Center’s Parent Handbook, which states that tuition is payable in advance and due in full on the first of each month. Statements are not sent out each month. You may pay your fees in full on the first of the month or half on the first and half on the fifteenth. In signing this form, I agree to this policy and commit to making tuition payments accordingly. I also understand that failure to comply with this policy may result in termination of services. In addition, I understand that a 30-day written notice must be submitted if I decide to withdraw my child from the program.

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