Busy Bee Academy 2011-2012 Contract

Name of Student: Age: Address: Home Phone: Name of Parent: Email Address: Allergies: Medications taken regularly: Closest Family Name: Birthday: Cell Phone:

Closest Family Phone:

Any change in address, phone number or emergency contact number MUST be given to Stephanie Dulgarian. Consent for Emergency Medical Treatment
I, the undersigned parent or legal guardian of______________________________, a minor, do hereby authorize StephanieDulgarian or any assistant in her classroom to call a physician, dentist or emergency medical personnel, to consent to an X-ray exam, anesthetic,medical or surgical diagnosis or treatment and hospital care which is deemed advisable by such personnel and rendered by such personnel. It is understood that this authorization is given in advance for any specific diagnosis, treatment or hospital care being required, but is given to provide authority & power in the part of our preschoolprovider listed above to give specific consent to any and all such diagnosis, treatment of hospital care which themedical personnel, in the exercise of their best judgment, may deem advisable. It is understood that aconscientious effort must be made to notify me before such action is taken. It is further understood that I releasethe preschool provider presenting this form of all liabilities connected with the transportation, diagnosis,treatment, hospital care and expense necessary for the treatment of my child.

Date:__________________ Legal Guardian Signature____________________________________________ Fee & Payment Agreement: I,_________________________ , agree to pay Stephanie Dulgarian for the preschool services according to the following:
The agreed monthly payment rate is: $50 for 1 day, $85 for 2 days. A one-time Materials Fee of $20 is due the first day of school. Payment is made to secure the position on my preschool roster. Payment is expected for each day regardless ofillness or should you decide to keep your child with you. Payment is due the first week of every monthand will be considered late if not received by then. A late fee of $5 will be added to your balance every weekthat payment is late. Your child may be asked to withdraw from my care if payment is more than 2 weeks late. Ifa child is picked up late, an additional charge of $5 will incur for every 10 minutes that they are in my care. If youknow you are going to be late, call me and special arrangements will wave this fee. I will work with you insituations out of your control (i.e. traffic) but chronic tardiness will not be tolerated. 2 Weeks advance notice isrequired if the child is to be permanently with drawn from my preschool. I will also give 2 weeks notice prior tostopping class, except in the case of gross misconduct on the part of the parent or child. Your child will only bereleased to someone listed below, or who I personally know.

Names of Persons Authorized to Take My Child From Facility:

1. Name: 2. Name: 3. Name: Relation: Relation: Relation: Phone Number: Phone Number: Phone Number:

By signing this agreement, I agree to comply with all the terms contained herein. Parent/Guardian Signature:__________________________________ Date:_______________________