Annual Form

Please review all linked documents and complete all sections.
Child's Name(Required)
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.

Child Medical Information

Address(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)

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.

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.

Handbook Policies

I acknowledge and agree to abide by the Approach to Discipline policy outlined in the Student Handbook. I acknowledge and agree to abide by the Health Policies outlined in the Student Handbook. I acknowledge and agree to abide by the No Smoking Policy outlined in the Student Handbook. I acknowledge the Shaken Baby Syndrome / Abusive Head Trauma Policy outlined in the Student Handbook. I acknowledge that I have access to the Student Handbook and will abide by all policies, procedures, and guidelines as provided.
Parent/Guardian Name(Required)
This acts as an electronic signature regarding the above information
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)

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)
MM slash DD slash YYYY