Peaceful Beginnings Early Childhood Center Before School, After School, and Summer Care Registration Form Please complete and submit. Name of Child(ren) * Gender * Male Female Age * Birth Date * MM DD YYYY T-Shirt Size * Name of Child(ren) Gender Male Female Age Birth Date MM DD YYYY T-Shirt Size Name of Child(ren) Gender Male Female Age Birth Date MM DD YYYY T-Shirt Size Parents/Guardians * Address * Email Address for Statements * Phone * Mother's Work Place & Address * Work Phone Number * Cell Phone Number * Driver's License Number * Father's Work Place & Address * Work Phone Number * Cell Phone Number * Driver's License Number * Childcare Childcare is available from 6:30 AM to 6:00 PM Monday through Friday, ages 6 weeks-13 years. Please select all times your Child(ren) will attend PBECC: Before School Care After School Care Non-School days Summer Camp Full-Time (5 days per week) Summer Camp Part-Time Authorized Person for Pickup & Emergencies * Please list those people who have permission to pick up your child(ren). Phone * (###) ### #### Authorized Person for Pickup & Emergencies * Phone * (###) ### #### Please list any people who are prohibited from picking up your child(ren): * Please list 2 emergency contacts we may call in the event that you cannot be reached: * Name Phone * (###) ### #### Name * Phone * (###) ### #### Authorization for Treatment * In the event that I cannot be reached in an emergency, I hereby give my permission to the physician selected by the Peaceful Beginnings Director or Director's Designee in the Director's absence to secure and administer treatment, including transportation and hospitalization, for my child(ren) named: * By typing my name in the field below, I am agreeing to the following statement: I understand that my child(ren) will be under proper supervision, and that all reasonable caution will be taken by those in charge of the program in order to prevent injuries. However, I will hold responsible neither the early childhood center, its personnel, nor Peace Lutheran Church in case of an accident. Medication Competency Statement I understand that by typing my name in the field below, I am agreeing to the following statement: I have determined PBECC Directors and Staff are competent to give or apply medication to my child(ren) as long as a signed Medication Form is on file. Health and Emergency Information * Should my child need local hospitalization, I prefer the following hospital: Name of Family Physician * Phone * (###) ### #### Name of Family Dentist * Phone * (###) ### #### Health Insurance Carrier * Please list any chronic or recurring illnesses, medical conditions, etc. * Does your child take any medications that will need to be administered while at Peaceful Beginnings? If yes, what medications, what dosage, and for what medical reason? * Please complete a medication form so we can record the time and dosage for each medication. Please list any dietary restrictions: * Please list any known allergies/reactions: * By typing my name below, I am agreeing to the statement: This health history is correct to the best of my knowledge, and the person herein described has permission to engage in all prescribed activities except as noted above. * By typing my name below, I am agreeing to the statement: Peaceful Beginnings strives to provide the best education, enrichment, and childcare to the children entrusted to our care. As a ministry of Peace Lutheran Church, we are a non-profit childhood center. However, we do incur expenses which are covered by the tuition each family pays. So that all expenses related to this ministry are covered, including appropriate staffing, food service, a portion of the utilities, and educational reinvestment and maintenance, the Officers’ Board of Peace Lutheran Church approved the following tuition and fees rates and attendance policies. * By typing my name below, I am agreeing to the statement: Each child will receive five sick/vacation days to be used from the day summer camp begins to the end of the school year. They do not have to be used consecutively. Please note that Christmas and school breaks are not separate; this policy change still applies. Changes in schedule (to allow sufficient time for staffing and planning): Any changes in childcare schedules will be coordinated with the director at least 2 weeks in advance of the change. * By typing my name below, I understand the statement: If you withdraw your child(ren) from our care, we require a two week notice. This notification must be given to the director in writing. If you withdraw your child from our care without a two-week written notice, we require a payment that equals the two weeks of tuition. * By typing my name below, I understand the statement: Late pick up fees: $5 per minute after 6:00 p.m. All ages in attendance. Weekly tuition is required to be paid in advance for care. All weekly tuition will be paid by Friday for the following week. If tuition is not paid by Monday at 6:00 p.m., a $10.00 late fee will be assessed and your child’s code will be deactivated. Your child(ren) will not be able to attend until all tuition and fees are paid. Peaceful Beginnings reserves the right to submit overdue accounts to collections. If extenuating circumstances prevent timely payment, please speak with the director to request a payment plan. * By typing my name below, I am agreeing to the following statement: I have received the DHHS Parent Information Brochure. * Peaceful Beginnings closes only when absolutely necessary due to inclement weather. As such, Peaceful Beginnings may be open when classes for District 145 schools have been cancelled due to weather. Please indicate whether or not you wish your child(ren) to attend Peaceful Beginnings on inclement weather days. If your child is scheduled to be at Peaceful Beginnings, but does not attend, you will still have the same weekly charge. * Yes, my child(ren) will attend Peaceful Beginnings on District 145 "Snow Days" No, my child(ren) will not attend Peaceful Beginnings on District 145 "Snow Days" By typing my name below, I understand: For the 2025 school year, tuition is listed below. The rate will remain the same regardless of the number of days your child attends. School-Out day tuition is ($44/day). Parents will be billed the difference in the tuition rate if your child attends on these days. You will be billed your regular weekly rate regardless if you attend on non-school days. *For early out days at 1:10p.m., we charge $22 for the afternoon. * Before Care - $37/Week; After Care - $60/Week; Before & After Care - $85/Week School-Out Daily Rate - $44/Day If your child will not be attending on a day for which s/he is scheduled, please notify Peaceful Beginnings that morning by phone with the reason for the absence. If childcare is needed on a day or at a time when a child is not normally scheduled, you must call ahead to ensure your child can be accommodated. Peaceful Beginnings does not guarantee care in these situations. * I have reviewed the Tuition, Fees, and Attendance Policies, and I have been given and have reviewed PBECC’s Parent Handbook. I learned about PBECC from: * Word-of-mouth Peaceful Beginnings Website Peace Lutheran Church Website Homepages Ad July 4th Parade Ad in the news (Waverly Newspaper) Sign along Amberly Road Other Thank you for submitting! 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