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

Child Medical Information

Name of Child's Doctor(Required)

Address(Required)

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

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