Annual Form Please review all linked documents and complete all sections. Child's Name(Required) First Last Do you have a child custody agreement for the child enrolled?(Required) If yes, a copy of the child custody agreement is required to be on file with the office prior to the child’s first day. Yes No Child Medical Information Name of Child's Doctor(Required) Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Doctor's Phone Number(Required) Preferred Hospital(Required) Hospital's Phone Number(Required) I agree that Independence Academy may authorize the physician of its choice to provide emergency care in the event that neither I nor the Child's Doctor listed above can be contacted immediately.(Required) I agree to the above policy Fees and Administrative Procedures I acknowledge and agree to abide by the Tuition Policy outlined in the Tuition Rates document on the Independence Academy website. I acknowledge and agree to abide by the Withdrawal Policy in the Tuition Rates document on the Independence Academy website. IA does not prorate of reimburse tuition for weather delays/closures or closures for communicable disease outbreaks. Tuition Rates (Required) I agree to the above policy Schedule of Available Care Drop off time is 8:15am to 9am. Early Care drop off is 7am to 8:15am. Dropping off after 9:15am requires prior notice. All children must be dropped off by 11:30am. (Required) I agree to the above policy Handbook Policies I acknowledge and agree to abide by the Health Policies outlined in the Student Handbook (Pg.25). Student Handbook Health Policy(Required) I agree to the above policy Handbook Policies I acknowledge and agree to abide by the Approach to Discipline policy outlined in the Student Handbook (pg.15). Student Handbook Approach to Discipline Policy(Required) I agree to the above policy Handbook Policies I acknowledge and agree to abide by the No Smoking Policy outlined in the Student Handbook (pg.25). Student Handbook No Smoking Policy(Required) I agree to the above policy Handbook Policies I acknowledge the Shaken Baby Syndrome / Abusive Head Trauma Policy outlined in the Student Handbook (pg.21). Student Handbook Shaken Baby Syndrome / Abusive Head Trauma Policy(Required) I agree to the above policy Handbook Policies I acknowledge that I have access to the Student Handbook and will abide by all policies, procedures, and guidelines as provided. Student Handbook Center Operational Policies/Student Handbook(Required) I agree to the above policy Handbook Policies I acknowledge that I have access to the Summary of Child Care Laws from the State of NC provided. Summary Of Child Care Law Summary of Child Care Law(Required) I agree to the above policy Nature Gear Guide I acknowledge and agree to abide by the Nature Gear Guide as provided. Nature Gear Guide Nature Gear Guide(Required) I agree to the above policy Parent/Guardian Name(Required) This acts as an electronic signature regarding the above information First Last Date(Required) MM slash DD slash YYYY Nutrition Opt-Out *Required for all students. IA only provides food in emergencies. I plan to provide all meals, snacks and drinks for my child and do not want his/her meals, snacks or drinks supplemented to meet the Meal Patterns for Children in Child Care Programs from the United States Department of Agriculture (USDA), which are based on the recommended nutrient intake judged by the National Research Council to be adequate for maintaining good nutrition. Since I opted out, if I do not provide all the meals, snacks or drinks for my child, I understand that the program will provide supplemental food and drink.(Required) I agree The below is an electronic signature. By typing your name and the date, you agree that you have read and agree to abide by all of the above information. Name(Required) First Last Date(Required) MM slash DD slash YYYY
