Caterpillars (Toddlers) 24/25 – SHED Childrens Campus

SHED Registration Form

Registration Fee: A registration fee of $75/child will need to be paid before submitting this form

SHED Caterpillars (Toddler Program) 24/25

"*" indicates required fields

Step 1 of 16

Section Break

Child's Name*

First Last

Name He/She/They like to be called

Child's Birth Date*

MM slash DD slash YYYY

SHED Fall 2024 Program Start Date:

MM slash DD slash YYYY

Child's Home Address*

Street Address Address Line 2 City State ZIP Code

Home Phone*

Child's Cell Phone (if not applicable write N/A)*

Program Information

All programs require a 30-day notice to make any schedule adjustments.

Please Select the SHED Program You're Registering For:*

Caterpillars (Toddler) WAITLIST

#1 Parent/Guardian Name*

First Last

#1 Parent/Guardian Cell Phone*

#1 Parent/Guardian Businessl Phone*

If not applicable please write N/A

#1 Parent/ Guardian Email*

#2 Parent/Guardian Name

First Last

#2 Parent/Guardian Cell Phone

If not applicable please write N/A

#2 Parent/Guardian Busines Phone

If not applicable please write N/A

# 2 Parent/Guardian Email

If not applicable please write N/A

Please list any special limitations or concerns you or your child may have including; dietary restrictions, allergies, chronic health conditions:

Child Identifying Information

Required by the Early Education and Care (EEC) Regulations:

Child's Eye Color*

Childs Hair Color*

Childs Skin Color*

Height*

Weight*

Sex*

Identifying Marks (if not applicable write N/A)*

Caterpillars Toddler Program

Please select days attending:

Caterpillars Full Time (8:30 AM - 3:30 PM)

Five days a week

Part Time (2 - 5 days) Full Days 8:30 AM - 3:30 PM

Monday

Tuesday

Wednesday

Thursday

Friday

Early Drop Off at 8 AM

Monday

Tuesday

Wednesday

Thursday

Friday

Extended Day until 6 PM

Monday

Tuesday

Wednesday

Thursday

Friday

Signature*

Date*

MM slash DD slash YYYY

SHED Children's Campus TRANSPORTATION AND RELEASE AGREEMENT 2024-2025

RELEASE INFORMATION I give my permission for my child to be released from SHED Children’s Campus at the end of the day to my spouse and/or to the following people. If no one other than you or your spouse is authorized, please indicate by writing NO ONE next to the NAME.

Full Name*

First

Phone*

Relationship*

Full Name*

First

Phone*

Relationship*

Full Name

First

Phone

Relationship

Full Name

First

Phone

Relationship

If there is anyone who is not allowed to pick up, please indicate below and speak with an Administrator. THIS PERSON MAY NOT PICK UP MY CHILD (if not applicable write N/A)*

(If you filled in this line, please speak with one of the directors.) I understand that unless otherwise notified, SHED Children’s Campus shall assume that all natural or adoptive parents or legal guardians of the enrolled child or children shall have equal access to the records kept by SHED Children’s Campus regarding the enrolled child or children. I understand that unless SHED Children’s Campus is provided with a certified copy of an order from a court of competent jurisdiction which expressly states otherwise, either natural or adoptive parent or legal guardian may visit or pick up the enrolled child or children on an unrestricted basis during the normal hours of operation during the day. I understand that if a child is not to be released to one of his/her parents, SHED Children’s Campus must have a certified copy of the court order and a photograph of the person in our records.

TRANSPORTATION AND RELEASE AGREEMENT Consent*

I fully understand and agree to the TRANSPORTATION AND RELEASE AGREEMENT

I understand that people who are listed under “Emergency Contacts” (next page) are authorized by me to pick up my child at SHED Children’s Campus in an “emergency” situation.

I understand that any other transportation requests must be stated in writing and maintained in the child’s file or the above plan must be implemented. This permission is valid from date of signature to the end of that program year.

I understand that SHED Children’s Campus will assume full responsibility for my child from the time he/she arrives
at the program until my child leaves the program according to the written instructions for departure.

My child will arrive & be picked up by parent/guardian:

Yes

If your child will not be dropped off or picked up by parent, please indicate directions:

Transportation Consent

I agree to the following policies:

If there is an alternative drop-off or pick-up person, I will call or email the directors to let them know.

If there is an alternate drop-off or pick-up person, I will call or email the directors to let them know.

Signature

Date

MM slash DD slash YYYY

SHED Children's Campus FAMILY INFORMATION FORM 2023-2024

Child's Name*

First Last

#1 Parent/Guardian*

First Last

Relationship to Child*

#1 Parent/Guardian Cell Phone*

#1 Parent Guardian Email*

#1 Parent/Guardian Business Phone (if not applicable write N/A)

#1 Parent Guardian Address*

Street Address Address Line 2 City State ZIP Code

Occupation (if not applicable write N/A)

Employer (if not applicable write N/A)*

Work Hours (if not applicable write N/A)

Employer/Place of Work Address

(if not applicable write N/A)

Street Address Address Line 2 City State ZIP Code

#2 Parent/Guardian

First Last

Relationship to Child

#2 Parent/Guardian Cell Phone

#2 Parent/Guardian Email

#2 Parent/Guardian Business Phone (if not applicable write N/A)

#2 Parent/Guardian Address if different from your child:

*You may leave this blank if not applicable

Street Address Address Line 2 City State ZIP Code

Occupation (if not applicable leave blank)

Employer (if not applicable leave blank)

Work Hours (if not applicable leave blank)

Employer/Place of Work Address (if not applicable leave blank)

(if not applicable write N/A)

Street Address Address Line 2 City State ZIP Code

Do either of you work for a large corporation?*

Yes

Who?*

(if not applicable write N/A)

Which Corporation?*

(if not applicable write N/A)

How did you hear about SHED Children's Campus?*

Does your child have siblings?*

Yes

Siblings Name

First

(if not applicable write N/A)

Siblings Age

(if not applicable write N/A)

Siblings Child Care Program Phone Number

(if not applicable write N/A)

Siblings Name

First

Siblings Age

Siblings Child Care Program

(if not applicable write N/A)

Please list any special interests or abilities your child may have:*

(if not applicable write N/A)

Is there a therapist or counselor that your child sees?*

(if not applicable write N/A)

Are there any medications your child takes on a regular basis? What does he/she take and why?

(if not applicable write N/A)

Please indicate any eating or sleeping problems:

(if not applicable write N/A)

Please list any child care or group experiences that your child has had prior to SHED Childrens Campus:

(if not applicable write N/A)

Please describe your childs personality:

(if not applicable write N/A)

Please indicate what languages are spoken at home:

(if not applicable write N/A)

Is there any other information you would like us to know about your child?

(if not applicable write N/A)

Parent/Guardian Signature*

Date

MM slash DD slash YYYY

SHED Children's Campus FIRST AID, CPR, EMERGENCY MEDICAL CARE, TRIPS AND PHOTOS AUTHORIZATION AND CONSENT FORM 2023-2024

Child's Name*

First Last

Date of Birth*

MM slash DD slash YYYY

First Aid & CPR Consent*

I agree to and fully understand the following policies.

I understand that the SHED Children’s Campus staff are trained in the basics of First Aid & CPR and I authorize them to give my child first aid when appropriate.

I understand that every effort will be made to contact me in the event of an emergency requiring medical attention for my child. I hereby authorize SHED Children’s Campus to call my physician and/or secure necessary medical care in case of illness or accident, to administer first aid, and CPR, when I cannot be reached and/or a delay, would be dangerous to the protection of my child. If I cannot be reached, I authorize SHED Children’s Campus to accompany my child in an ambulance transport to the nearest hospital for medical treatment including administration of anesthesia if surgery is advised by a physician.

Name of Hospital*

Child Physicians name:*

Phone*

Physicians Address*

Street Address Address Line 2 City State

Health Insurance Coverage:*

Policy #*

Child’s Allergies:*

(if not applicable write N/A)

Chronic Health Conditions*

(if not applicable write N/A)

Non Parental/Guardian Emergency Contacts (in order to be contacted)

Emergency Contact #1 Name*

First Last

Relationship to Child*

Phone*

Address*

Street Address Address Line 2 City State

Emergency Contact #2 Name*

First Last

Relationship to Child*

Phone*

Address*

Street Address Address Line 2 City State

Emergency Contact #3 Name

First Last

Relationship to Child

Phone

Address

Street Address Address Line 2 City State

General Consent: Trips, Photos, Sunscreen and Bug Spray

I hereby authorize SHED Children’s Campus to allow my child to participate in the following: (please check all that you agree to)

Field trips (special permission required for bus trips)

Walks (local, library, downtown, AVIS trails, Phillips Academy Bird Sanctuary, etc.)

Photos (for SHED Children’s Campus / Kid’s Club use to release to newspapers)

Photos (for SHED Children’s Campus / Kid’s Club to use on our website & Facebook / Instagram page

Bug Spray & Sunblock: I herby authorize SHED Children's Campus to apply as needed:*

Sunscreen (45 SPF)

Bug Spray (7% DEET)

Diaper Cream

By checking the box you fully agree and give SHED Children's Campus permission to apply the following: (if you do not grant permission please leave the box unchecked)

Signature*

Date*

MM slash DD slash YYYY

SHED Childrens Campus FINANCIAL AGREEMENT FORM 2024-2025

Consent*

I fully understand and agree to SHED's following financial terms

I understand tuition is divided evenly over 10 months and I am responsible for the payment of my child's monthly program fees.

I understand there is an annual Facility Fee ($300 for 1 child / $500 per family).

Those in the SHED Before School ONLY are not responsible for a facility fee

I understand that SHED Children’s Campus registration fee is due with registration and is non-refundable.

SHED Children’s Campus does not bill; payment is due the first day of each month. Checks should be made payable to SHED Inc. Checks can be mailed or dropped off. Payment can be made on your account on Brightwheel. Payment can also be made by credit card on our website (convenience fee will be additional).

I understand that if my payment is not received by the 5th of the month it is due, I will be charged a $30.00 late fee.
Unpaid late fees will accrue on the account.

I understand that I may only register my child for the following year if my account is up to date and clear of any debts.

I will give 30 days' notice, in an email, prior to changing my child’s schedule or to withdraw them from the program.

I understand that I must consider my needs very carefully and no schedule changes may be made between August 1st and the end of September. After that, I may request changes which will be honored by SHED Children’s Campus if possible.
I further understand that I can only make 3 changes to my child’s schedule during the school year; after that, there will be a $30 processing fee per family per schedule change.

I understand that SCC is open according to the published calendar. SCC is closed on most holidays, winter holiday break, 4th of July week & 2 professional development days.

SCC is open on a sign-up, additional fee basis ($80.00/$90.00 per day) during the other school vacation weeks (February and April) and the In-Service & half days.

I understand there is a $10 late fee – per day if I sign up for a vacation or in-service day after the deadline.

I understand that SHED Children’s Campus reserves the right to close during the day on a snow day if the weather is deemed unsafe or very extreme. SCC will email families & post a message on our voicemail with opening or closing decisions.

I understand that in the event of any absences or personal vacations during the program hours, I am still responsible for fees for time reserved, not actual time spent at the Program.

I understand that all children are accepted into SHED Children’s Campus on a two-month trial basis. If SHED Children’s Campus cannot accommodate the needs of my child, SHED Children’s Campus will provide help in finding another placement.

I understand that if my child is going to be absent I need to call or email SHED Children’s Campus to let them know.

I understand I need to read the Parent Handbook (can request a copy from the directors) & be responsible for following the guidelines it contains.

I agree to adhere to the stated policies and procedures of SHED Children’s Campus and give my child permission to participate fully in this program.

I would like to receive a dependent care receipt for my tuition payment each month?*

Yes

Consent*

I agree to the following policy.

I understand tuition is divided evenly over 10 months and I am responsible for payment of monthly fees.

My Monthly Payment Amount*

Please enter below the dollar amount of your monthly fee.

Signature*

Date*

MM slash DD slash YYYY

SHED Children's Campus 2024-2025 Child Medical Alert Form

If your child has an allergy/medical condition, please fill out this form.

Child's Name

First Last

Has an Allergy/Medical Condition

In helping us appropriately and safely deal with a situation involving your child in this concern, please complete the following:

How do you normally handle this concern?

How would you like us to respond if this concern arises?

Is there anything that triggers or complicates this situation?

Is there anything that your child should avoid doing?

What is it / Are there any medical limitations that we should be aware of?

Are there things that you find can make the situation worse?

Are there things that you find can make the situation better?

Are there any non-emergency situations that you would prefer to be phoned by a staff member to alert you to a given situation?

Signature

Date

MM slash DD slash YYYY

Tooth-brushing Authorization or Waiver

Our licensing Agency, EEC has established a new policy regarding tooth-brushing. The policy states that if a child is in a program for more than 4 hours and if he/she eats a meal while at the program, then the child should have the opportunity to brush his/her teeth. Parents may, however, sign a statement indicating that their child does not need to brush while at the program.

Please choose one of the following:*

Yes, I would like my child to brush his/her teeth while at Kid’s Club (full days and vacation weeks). I will supply a toothbrush and a tube of toothpaste for his/her/their use. I will label both the toothbrush and the toothpaste with my child’s name. I will replace the toothbrush every 3 months.

No, I do not want my child to brush his/her/their teeth while at SHED Children’s Campus.

Signature*

Date*

MM slash DD slash YYYY

SHED, INC. Permission Form for Use of Minor's Picture On the Internet

(A minor is any person 17 years of age and younger.) This letter is a request for permission to use photographs of your child on the: • Official SHED, Inc. Web Site on the Internet • SHED, Inc. Facebook, Instagram & Twitter page on the Internet • In SHED, Inc. promotional literature. The images are used on the Internet to promote a wide range of activities, however; the use of images is strictly controlled to best assure safety and confidentiality. Images displayed on the Internet will not be identified by name or any other identifying information. Please return the form on the back to indicate that your child's picture may or may not be used on the Internet. This permission will stay in effect until canceled by the parent or guardian. If you wish to cancel your permission and have your child's picture(s) removed, please contact the Webmaster at 978-684-5055 (Linda) and the pictures will be removed. Allow 3-5 working days for removal. Thank you for your cooperation. Linda Shottes-Bouchard Executive Director SHED Inc. 65 Phillips Street ~ Andover, MA 01810 ~ 978-684-5055 ~ FAX 978-636-4800 ~ www.shedchildrenscampus.org

SHED, Inc. Permission Form for Use of Minor's Picture On the Internet

Internet PHOTO Release Consent*

Yes, my childs picture may be used

No, my childs picture may not be used on the Internet

Child's Name*

First Last

Acknowledgement (if you consented yes)

I have read the following:

As the parent or legal guardian, I grant SHED, Inc. permission to use my child's picture on the

Official SHED, Inc. Web Site on the Internet,
SHED Facebook or Instagram page on the Internet
In SHED promotional literature.

I understand that at any time, I may have my child's picture removed by contacting the SHED, Inc. Webmaster. It is
agreed that the use of my child’s photograph or photographic image shall in no way be used in any other forum other than for official SHED, Inc. business.
I hereby waive any right that I may have to inspect or approve the finished product and the advertising copy and/or other matter that may be used in connection therewith or the use to which it may be applied.
I do hereby release, acquit and forever discharge SHED, Inc., its officers, employees, attorneys, representatives, insurers and assigns from any and all demands, cause of action and/or judgments of whatsoever nature of character, past or future, known or unknown, whether in contract or in tort, whether for personal injuries, property damage, payments, fees, expenses, accounts receivable, credit, refunds, or any other monies due or to become due, or damages of any kind or nature, and whether arising from common law or statute, arising out of, in any way, the use of my photograph or photographic image for official SHED, Inc. business through its Website, Facebook page, Patch or SHED, Inc. promotional literature.
This release contains the entire agreement between the parties and shall be binding upon and inure to the benefit of the successors and assigns of the undersigned.

Parent/Guardian Signature*

Date*

MM slash DD slash YYYY

MEDICAL EMERGENCY TREATMENT: I hereby give SHED Children's Campus permission to administer basic first aid and/or CPR to my child, and/or take my child, to a hospital to secure medical treatment when I cannot be reached or when delay would be dangerous to my childs health.

Signature*

Date*

MM slash DD slash YYYY

Dear Families.

SHED Children’s Campus is a wonderful family unit for all of us. We understand that family life is busy – filled with responsibilities, obligations, home life, school & work life, play and all of the fantastic extras. We are honored to be a part of your life and we recognize that some of your children’s time here comes with guidelines. We hope this form will help define some of those responsibilities. There are many extra days to sign up for, times to be here by, phone calls to make, etc.

Child's Name*

First Last

Here is a list of some of the things we ask you to remember:*

By checking the box you acknowledge acceptance of the following terms:

I understand if my child will be absent from SHED Children’s Campus, I need to let SCC know about this absence by phone call or email.

I understand if I need to make a change in my child’s schedule, I must contact the directors. There is a 30 day notice before tuition can be reduced.

ALL SHED Programs Consent:

I acknowledge and accept the following:

I understand if my child attends on a day that is outside of the monthly tuition base (vacation, in-service, half day, or snow day), that day does incur a fee.

I understand if my child needs to attend on a vacation, in-service, or half day, I must sign up for this day beforehand. I must sign up EVEN if it is my child’s regularly scheduled day. Sign-ups for these days go out by email or Brightwheel one to two weeks before the scheduled day. You can sign up by responding to the email, by phone call, or in person.

I understand I must pay for the half days or in-service days by the deadline (usually a week before the date).

I understand if I sign up for half days, in-service days, or vacation days after the deadline, space is not guaranteed & there is a $10 late fee.

I understand I must cancel a sign-up 48 hours in advance or I will be responsible for the fee.

I understand Shed Children's Cmapus closes at 6 pm. If I arrive later than 6 pm, minutes will start accruing towards the 15-minute grace time allotted each year. Any minute after that grace time equals $2 in late fees
I understand and fully comply with the SHED Children's Campus Handbook.

I understand SHED Children’s Campus is dedicated to caring for my child as an individual and will find ways to enhance my child’s imagination & curiosity.

SHED Children’s Campus understands you have entrusted us with your most precious loved ones. We will do our very best each and every day to respect and appreciate the trust you have placed in us. Warmly, SHED Children’s Campus Administration & Educators

Signature*

Date*

MM slash DD slash YYYY

SHED Children’s Campus Family Contact List Authorization 2024-2025

The SHED Childrens Campus Contact List will contain the names, addresses, telephone numbers, email addresses, and parents names of all the students in the program whose families wish to participate. The contact list will be broken down by program (Monarch, Springboard to Kindergarten, Kids Club). Once compiled, a copy of the list will be distributed to each family. All parents should complete the bottom portion of this form indicating their wishes concerning the directory. Please return it with your other enrollment forms ASAP so we may expedite the directory distribution in the fall.

Would You like to include your child, in the Family Contact List?*

Yes

If you answered yes, please fill out the below fields:

You have my permission to print the following information:

Child's Name

First Last

Guardian Name

First Last

Home Phone

Cell Phone

Address

Street Address Address Line 2 City State ZIP Code

Guardian Name

First Last

Home Phone

Cell Phone

Address

Street Address Address Line 2 City State ZIP Code

Children's Campus 2024-2025 Developmental History

You may skip this page if your child does not attend Caterpillars, Monarch, or Springboard programs.

Child's Name

First Last

Birth Date

MM slash DD slash YYYY

Child's Personal History

Any complications at birth?

Any developmental delays (sitting, crawling, walking)?

Any difficulties speaking?

Yes

Any other languages spoken at home?

Does your child see a counselor/therapist?

Yes

For what reason?

Any other helpful information?

Health

Any serious illness or hospitalization?

Any physical disabilities/limitations?

Any allergies?

Any medications given regularly?

For what?

Eating

List any eating problems:

Food allergies?

Favorite Foods:

Any food refused?

Toilet Habits

Does child indicate his/her bathroom needs:

Yes

Sometimes

Does child have accidents?

Yes

Sometimes

Are there any specific words of which we should be aware to indicate bathroom needs?

Sleeping Habits:

Does child still take naps?

Yes

Sometimes

What time does child get up in the AM

What time does child go to bed?

What does child take to bed?

Social Relationships:

Has child had other child care experiences?

Yes

Where?

How long did he/she/they attend other program(s)?

Is your child involved in other outside activities?

How does your child relate to strangers?

What is your child’s favorite toy?

Is he/she/they frightened by...

Please check all that apply.

Animals

Rough children

Loud noises

Storms

The dark

Other?

Does your child have any pets?

How would you describe your child?

Signature

Date

MM slash DD slash YYYY

2024/2025 Registration Fee

You will be billed the $75 SHED registration fee only when your child is removed from the waitlist and fully registered for Caterpillars Toddler Program.

This field is for validation purposes and should be left unchanged.

SHED Registration Form

SHED Caterpillars (Toddler Program) 24/25

Section Break

Program Information

Child Identifying Information

Caterpillars Toddler Program

SHED Children's Campus TRANSPORTATION AND RELEASE AGREEMENT 2024-2025

SHED Children's Campus FAMILY INFORMATION FORM 2023-2024

SHED Children's Campus FIRST AID, CPR, EMERGENCY MEDICAL CARE, TRIPS AND PHOTOS AUTHORIZATION AND CONSENT FORM 2023-2024

Non Parental/Guardian Emergency Contacts (in order to be contacted)

SHED Childrens Campus FINANCIAL AGREEMENT FORM 2024-2025

SHED Children's Campus 2024-2025 Child Medical Alert Form

Tooth-brushing Authorization or Waiver

SHED, INC. Permission Form for Use of Minor's Picture On the Internet

SHED, Inc. Permission Form for Use of Minor's Picture On the Internet

MEDICAL EMERGENCY TREATMENT: I hereby give SHED Children's Campus permission to administer basic first aid and/or CPR to my child, and/or take my child, to a hospital to secure medical treatment when I cannot be reached or when delay would be dangerous to my childs health.

Dear Families.

SHED Children’s Campus understands you have entrusted us with your most precious loved ones. We will do our very best each and every day to respect and appreciate the trust you have placed in us. Warmly, SHED Children’s Campus Administration & Educators

SHED Children’s Campus Family Contact List Authorization 2024-2025

If you answered yes, please fill out the below fields:

Children's Campus 2024-2025 Developmental History

Child's Personal History

Health

Eating

Toilet Habits

Sleeping Habits:

Social Relationships:

2024/2025 Registration Fee

Call Us To Book A Tour

We'd love to have you join us while class is in session.
Please give us a call today to schedule your tour.

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Find Us

Programs

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Get In Touch

SHED Registration Form

SHED Caterpillars (Toddler Program) 24/25

Section Break

Program Information

Child Identifying Information

Caterpillars Toddler Program

SHED Children's Campus TRANSPORTATION AND RELEASE AGREEMENT 2024-2025

SHED Children's Campus FAMILY INFORMATION FORM 2023-2024

SHED Children's Campus FIRST AID, CPR, EMERGENCY MEDICAL CARE, TRIPS AND PHOTOS AUTHORIZATION AND CONSENT FORM 2023-2024

Non Parental/Guardian Emergency Contacts (in order to be contacted)

SHED Childrens Campus FINANCIAL AGREEMENT FORM 2024-2025

SHED Children's Campus 2024-2025 Child Medical Alert Form

Tooth-brushing Authorization or Waiver

SHED, INC. Permission Form for Use of Minor's Picture On the Internet

SHED, Inc. Permission Form for Use of Minor's Picture On the Internet

MEDICAL EMERGENCY TREATMENT: I hereby give SHED Children's Campus permission to administer basic first aid and/or CPR to my child, and/or take my child, to a hospital to secure medical treatment when I cannot be reached or when delay would be dangerous to my childs health.

Dear Families.

SHED Children’s Campus understands you have entrusted us with your most precious loved ones. We will do our very best each and every day to respect and appreciate the trust you have placed in us. Warmly, SHED Children’s Campus Administration & Educators

SHED Children’s Campus Family Contact List Authorization 2024-2025

If you answered yes, please fill out the below fields:

Children's Campus 2024-2025 Developmental History

Child's Personal History

Health

Eating

Toilet Habits

Sleeping Habits:

Social Relationships:

2024/2025 Registration Fee

Call Us To Book A Tour

We'd love to have you join us while class is in session. Please give us a call today to schedule your tour.

Join Our Mailing List

Find Us

Programs

Explore

Get In Touch

We'd love to have you join us while class is in session.
Please give us a call today to schedule your tour.