Growing Minds Registration

Parent Name #1*

First Last

Parent #1 Email*

This email will be used for communication with Growing Minds staff.

Enter Email Confirm Email

Parent #1 Phone*

Parent #1 Address*

Street Address Address Line 2 City State ZIP Code

Parent #1 Employer

Parent #1 Work Phone

Parent #1 Work Address

Street Address Address Line 2 City State ZIP Code

Parent Name #2

First Last

Parent #2 Email

This email will be used for communication with Growing Minds staff.

Enter Email Confirm Email

Parent #2 Phone

Parent #2 Address

Street Address Address Line 2 City State ZIP Code

Parent #2 Employer

Parent #2 Work Phone

Parent #2 Work Address

Street Address Address Line 2 City State ZIP Code

Primary emergency medical contact (OTHER THAN PARENTS ABOVE)*

Primary emergency medical contact phone*

Primary emergency medical contact relationship to student(s)*

Student Enrollment*

How many students do you want to enroll in Growing Minds Learning Center?

Student #1 Start Date*

What date will your Student #1 be starting Growing Minds Learning Center?

Student #1 Name*

First Middle Last

Student #1 resides with?*

Student #1 Gender*

Student #1 Ethnicity*

Student #1 language spoken if English is not primary language*

Student #1 Birthday*

Has Student #1 or a sibling ever attended B.A.S.E., Summer Camp, or YSPP in the past?*

Yes
No

Will Student #1 need before or after care?*

Please note that before and after care are free of charge for students enrolled in Growing Minds. However, if student attends during breaks or other days of full-day care, fees will apply.

For Student #1, you selected "Yes - As needed" attendance option. Please provide more detail.*

Please indicate likely dates of attendance if sporadic.

Do you anticipate Student #1 needing summer care?*

Yes
No

Is Student #1 potty trained?*

Yes
No

Student #1 Dentist*

Student #1 Dentist Phone*

Student #1 Physician*

Student #1 Physician Phone*

Student #1 Physician Address*

Street Address Address Line 2 City State ZIP Code

Student #1 Allergies*

Type NA if none.

Student #1 Medical Needs*

Type NA if none. If medical administration is needed by our staff, the Medical Release form will need to be signed. Please provide the medication name that your child is taking, the dosage, and the frequency.

Student #1 Behavior Issues or Concerns*

Type NA if none.

Student #2 Start Date*

What date will your Student #2 be starting YSPP?

Student #2 Name*

First Middle Last

Student #2 resides with?*

Student #2 Gender*

Student #2 Ethnicity*

Student #2 language spoken if English is not primary language*

Student #2 Birthday*

Has Student #2 or a sibling ever attended B.A.S.E., Summer Camp, or YSPP in the past?*

Yes
No

Will Student #2 need before or after care?*

Please note that before and after care are free of charge for students enrolled in Growing Minds. However, if student attends during breaks or other days of full-day care, fees will apply.

For Student #2, you selected "Yes - As needed" attendance option. Please provide more detail.*

Please indicate likely dates of attendance if sporadic.

Do you anticipate Student #2 needing summer care?*

Yes
No

Is Student #2 potty trained?*

Yes
No

Student #2 Dentist*

Student #2 Dentist Phone*

Student #2 Physician*

Student #2 Physician Phone*

Student #2 Physician Address*

Street Address Address Line 2 City State ZIP Code

Student #2 Allergies*

Type NA if none.

Student #2 Medical Needs*

Type NA if none. If medical administration is needed by our staff, the Medical Release form will need to be signed. Please provide the medication name that your child is taking, the dosage, and the frequency.

Student #2 Behavior Issues or Concerns*

Type NA if none.

Authorized pick-up person(s)*

All authorized pick-up persons must be registered. Parents do not need to be listed as an authorized pick-up person. How many authorized pick-up persons do you want to register?

Authorized Pick-up Person #1*

Please inform pickup persons to bring ID in order for child to be released; please let us know when someone other than a parent will be picking up child(ren) up.

First Last

Authorized Pick-up Person Phone #1*

Authorized Pick-up Person #2*

Please inform pickup persons to bring ID in order for child to be released; please let us know when someone other than a parent will be picking up child(ren) up.

First Last

Authorized Pick-up Person Phone #2*

Authorized Pick-up Person #3*

Please inform pickup persons to bring ID in order for child to be released; please let us know when someone other than a parent will be picking up child(ren) up.

First Last

Authorized Pick-up Person Phone #3*

Authorized Pick-up Person #4*

Please inform pickup persons to bring ID in order for child to be released; please let us know when someone other than a parent will be picking up child(ren) up.

First Last

Authorized Pick-up Person Phone #4*

Payment method*

Please note there will be a convenience fee charged for all electronic forms of payment including credit card, debit card, e-check/bank transfer. Paper checks issued by bank on your behalf are not considered E-checks and are not charged a convenience fee. If you select Debit/Credit Card option below, right click on this link NOW, select “Open link in new tab”, and follow payment authorization steps >> Credit/Debit Authorization

Debit/Credit Card
E-check/ACH Bank Transfer
Paper Check/Bank Check
Other

Parent Agreement Consent*

GROWING MINDS LEARNING CENTER

PARENT AGREEMENT

***PLEASE READ THE FOLLOWING COMPLETELY – YOU ARE MAKING MULTIPLE AUTHORIZATIONS BY SIGNING THIS DOCUMENT, INCLUDING MEDIA RELEASE, GENERAL LIABILTY RELEASE, TRANSPORT RELEASE, MEDICAL RELEASE, and more:
I agree to the following with regard to my child’s enrollment in the Growing Minds program:

1. I understand that enrollment in Growing Minds is based on a monthly enrollment fee. If circumstances should occur which would require my child(ren)’s withdrawal, I understand 30 days’ notice is required, and that one installment payment will be due as a penalty for such withdrawal. This will be in addition to any monies due and owing for regular attendance.
2. I agree to be responsible for all expenses incurred for medical and/or emergency transportation costs;
3. I agree that an authorized adult will pick up my child each day from Growing Minds Learning Center;
4. I understand that all MHABC/Growing Minds personnel are mandated to report any signs of abuse or neglect;
5. I have provided all necessary information and required forms regarding my child(ren)’s medications, allergies and medical conditions. I understand that if my child uses an Epi-pen or similar device, I MUST provide this to the MHABC/Growing Minds administration prior to my child’s enrollment and attendance.
6. I understand that I and the other parent may initially be required to present a photo I.D. when picking up my child until site staff becomes familiar with us. I understand that when a person other than myself or the other parent will be picking up my child, that individual needs to be on the authorized pickup list and must provide a picture ID in order to be permitted to pick the child up. I further understand that if I need to make a change to the authorized pickup list, I must do so in writing to pfettig@mhaboonecounty.org by using the email listed on my MHABC/Growing Minds account, preferably with a 24 hour notice. If I am unable to give a 24 hour notice of a change, I will call the MHABC office at (765) 482-3020 x100 and inform staff of the change, and also do so in writing to pfettig@mhaboonecounty.org.
7. I understand that if custody or a protective order are an issue affecting who may or may not pick up my child(ren), I will IMMEDIATLEY communicate this to MHABC administration at 765-482-3020 x100 and provide a copy of the relevant court order. I understand that without a court order stating otherwise, MHABC/Growing Minds staff cannot prevent a legal parent from picking up a child.
8. I understand MHABC reserves the right to exclude any child from Growing Minds or request that a child be picked up from the program should the child be exhibiting symptoms of illness, where those symptoms would require exclusion due to the potential for spread of illness; I understand this could affect my childcare plans and that I should have backup plans in place should this occur.
9. I understand that my child may be denied enrollment until this registration is submitted and processed, and until required documents are submitted, such as birth certificate and vaccination records;
10. I understand my child(ren) can be denied attendance in the case of non-payment;
11. I understand that a late fee of $40.00 may be added each month as a result of an unpaid or late-paid invoice(s), and that a 2% compounded interest rate will be assessed monthly on balances carried more than 30 days;
12. I understand I must pick up my child(ren) promptly at 3:45 p.m. (or have another approved adult do so, or make arrangements for the child to attend aftercare (available until 6:00 p.m.), or a $5.00 per minute, per child fee will accrue and will be expected to be paid immediately to the MHABC office;
13. I understand that Growing Minds focuses on outdoor learning as a primary component of their curriculum and that my child will spend roughly 60-75% of their time outdoors. I understand that this will be the case regardless of the weather, with exceptions being bitterly cold windchill, lightning, and when any weather scenario has been declared an emergency. Otherwise, I understand it is Growing Minds’ intent to have children outside as often as possible, and that necessary accommodations will be made so that learning in most weather circumstances is reasonable (i.e. shade, providing water, providing regular breaks if necessary, etc.). I further understand I must provide required items to make outdoor learning achievable for my child (rain suit, winter coat and snow pants, gloves, hat, scarf, snow and rain boots, etc.) and that these items will receive wear and tear. I am prepared to replace these items when and if needed at my own cost.
14. I/we, the parent(s) of the registered child/ren, acknowledge that I/we are responsible for any unpaid balance of enrollment fees, late fees, interest and finance charges associated with my/our account;
15. I/we, the parent(s) of the registered child/ren, acknowledge that I/we are responsible for attorney’s fees required for purposes of collection any unpaid fees herein, plus any and all costs of collection, including court fees.
16. I/we, the parents of the registered child/ren, acknowledge we have read the Growing Minds Parent Handbook and agree to abide by its processes and procedures.
17. I agree to join internal communication apps/channels for my child’s classroom to stay up to date on activities, announcements, and other important information;
18. I/we acknowledge that we sign this document of our own free will and understand we may have it reviewed by a legal practitioner prior to signing.

Media release: I hereby authorize MHABC and Growing Minds staff to capture, edit and use my child’s video and photographic image solely for the purposes of sharing information about the Growing Minds program and for promoting and advertising the program on the Growing Minds and MHABC social media pages and website, in newspapers, newsletters, via email and other forms of media. In doing so, I release MHABC and Growing Minds staff from all claims, demands, and liability whatsoever in connection with the above. PARENT: IF YOU DO NOT WANT YOUR CHILD’S IMAGE USED IN THE MANNER DESCRIBED ABOVE, PLEASE CONTACT MHABC IN WRITING AT PFETTIG@MHABOONECOUNTY.ORG WITHIN 48 HOURS OF SUBMITTING THIS REGISTRATION AND ADVISE YOU DO NOT WANT YOUR CHILD’S IMAGE USED. PLEASE MAINTAIN RECORD OF SUCH COMMUNICATION. *I understand that my child’s photograph may also be taken for purposes of sharing with me on the internal communication app referenced above which will be private to only me and the families in my child’s class.

Transportation Release: I authorize MHABC/Growing Minds to transport my child for purposes of receiving necessary medical attention when treatment is time-sensitive and I am not available. I recognize and acknowledge that there are certain risks of physical injury associated with being transported by bus/car by an MHABC staff member. I agree to assume the full risk of injuries that may be sustained by any minor child/ward of mine, as a result of being transported by bus/car by an MHABC staff member. I agree to waive and relinquish all claims on behalf of my minor child/ward that the minor child/ward may have against MHABC as a result of the minor child/ward’s being transported by bus/car/other vehicle by an MHABC staff member.

Medical Treatment Release: I hereby consent to emergency medical treatment of my child(ren), herein registered, during BASE operation hours, should I not be able to be reached, to assure prompt treatment and prevention of undue delay. I understand such treatment, other than first aid required to be rendered immediately by an MHABC/Growing Minds staff person, will be provided by either a licensed physician or trained emergency care technician.

General Release of Liability: I, individually, and on behalf of my minor child (or children) and our respective heirs, successors, assigns and personal representatives, hereby release, acquit and forever discharge Mental Health America of Boone County, Growing Minds Learning Center, and their administration, staff, site leaders, designated volunteers, agents, board members, officers, trustees and representatives (in their official and individual capacities) from any and all liability whatsoever for any and all damages, losses, injuries or illnesses, including death, to persons or property or both, including but not limited to any claims, demands, actions, causes of action, damages, costs, expenses and attorney’s fees, which arise out of, during or in connection with my child’s (or children’s) participation in the aforementioned activities, including but not limited to any damages, losses, illnesses or injuries to persons or property or both, which may be sustained or suffered by my child or any person in connection with my child’s (or children’s) association with, or participation in, activities at, sponsored by, or arising out of MHABC/Growing Minds activities.

I agree to the Parent Agreement below

Parent Signature*

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Growing Minds Learning Center Registration