Pride Academy Registration Form

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***idenification (Stsate ID, Driver's License, Passport) is required in order for an individual to pickup your child


I, the parent/legal guardian of the above listed child(ren) hereby authorize emergency medical treatment for my child in the event I cannot be responsible for the cost of such treatment.

I, the parent/legal guardian of the above listed child(ren) hereby give permission for my child(ren) to take field trips with his/her caregiver.

The following MUST be complete prior to the child's start date:

  • Complete Registration Packet
  • Physical/ Well Child Check-up signed and dated by physician (Within 60 days)
  • Immunization Records (must be current)
  • Birth Certificate
  • Extra change of clothing
  • Unopened items (if needed): Diapers, wipes, baby food, infant formula and water
  • Blanket for naptime
  • First week's payment (cash paying, CCDF co-payments and/or CCDF overages)
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(Indicate month / date / year)



IPV (Polio)

Influenza (Flu) *

* Recommended yearly

Measles Mumpsl Rubella (MMR)

Rotavirus (RGE)

Varicella (Chicken Pox Disease)

Pneumococcal I (PCV) (Prevnar)



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the parent/guardian of the above listed child(ren) hereby authorize adult employees (over age 18) of Pride Academy to provide transportation and consent to necessary medical treatment for my minor child(ren). The consent is not limited, but may include authorization for certified medical personal to perform examinations, health treatment,.and physical diagnosis, administer anesthetic, execute-surgery, or any medical treatment and/or hospital care to be rendered to the above minor children. Medlcal consent must be given under the g􀊮neral supervision and/or advice of any physician or surgeon licensed to practice medicine in the state of Indiana in the case that I cannot be contacted. This authorization of consent is valid for limited ten (l0) year period.

Emergency Preparedness Plan Notification

I, the parent/guardian of the above listed child(ren) hereby acknowledge, I have received a copy of the Pride Academy's Emergency Preparedness Plan in my Parent Handbook. By signing below I am stating that I fully understand this plan and the course of action that will be taken by Pride Academy in the event of an emergency. A written emergency plan is established and implemented. The plan is shared with the parents at the time of enrollment and/or any time the provider initiates a change in any aspect of the plan. The purpose of the written emergency plan is that all emergency policies and I procedures are clear to the parents. I The plan is to be signed by the parents to indicate their understanding and acceptance of the policies and procedures. The written Pride plan will notify parents immediately in the event that a staff member becomes contagious from illness, or any other emergency that will prevent children from being cared for in this facility. There will also be a backup plan for care that the facility will arrange in an event of an emergency. The parent(s) will need to have a backup plan for care in place in the event of their child's illness or the facilities inability to care for the children. Exclusion policies pertaining to a child's health, alternative contacts, and medical care authorization are available in case1 the parents cannot be reached in an event of an emergency. A list will also be provided by the parents of who is authorized to pick up the children. A plan for fire evacuation or any type of evacuation will be posted on the parent board located in the office. A plan for safe shelter during a tornado or any other threatening weather emergency will take place in the cafeteria located in Pride Academy.

Early Emergency Dismissal

In the event of an early emergency dismissal, we would like to make certain a child will be sent to a location where there will be adult supervision. Therefore, we are asking you to specify where your child will go if students are unexpectedly sent home early.

In case of an emergency early dismissal, I want my child to:
This form will remain in your child's file folder. If these plans should change, it is your responsibility to immediately inform Pride Academy.
*Should Pride Academy experience an evacuation at any of the above listed facilities, we will immediately transport children, in company insur􀀢d vehicles, to another Pride Academy location listed above. It is crucial that the parent keep all contact information up to date and current.

Emergency Information & Authorization For Release Addendum

In the event of an emergency I am unable to be reached, the following individuals are authorized to drop­off and pick-up my chil􀁍(ren). I understand photo identification is required to release my child(ren).

Disciplinary Model Notification

We at Pride Academy have implemented a disciplinary model which consists of the following:

  • "Peace Table" - The "peace table" instills conflict resolution with out children. If your child is in a disagreement with another student, the drildren will go to the "peace table" and learn to resolve the issue. If the issue is not resolved within 2-3 minutes the tea,cher will help the children to understand the importance of sportsmanship􀄮 personal space and respecting their classmates.
  • "Stop Sign,, Reward System - The "stop sign" will consist of green, red, and yellow lights. Each child will be given a color for the day (green, yellow, or red). At the end of each we􀅹k, every student that has all green buttons on the rewards calendar will receive a prize out of the treasure box.
  • Green = Green day
  • Yellow= Caution. Spoke to about behavior on at least 3 separate occasions.
  • Red= Disruptive and interrupted class more than 3 times on one day.
  • "Parent Contact" - ea¢h week we strive to provide an array of opportunities for our children. If a teacqer speaks to our children more than 3 times in one day, a parent will be contacted. If the problem persists for two consecutive days, the child will be suspended for one day from Pride Academy.
We are striving to be #1 in teaching, loving; nurturing and 􀇜powering our children. Please help us to be an even better blessing· to the children of Pride Academy.


Pride Academy recommends back sleeping for all babies. At Pride Academy we must place an infant in a crib to sleep directly on a firm mattress and must position the infant on his/her back to sleep unless there is a signed directive from a parent or legal guardian for an alternate sleep position. Car seats, swings, couches, rockers or on the floor are not acceptable as an alternative sleep position.

Pride Academy uses a fitted crib sheet that fits tightly on the mattress and overlaps the mattress so it cannot by dislodged by pulling on the corner of the sheet. Pride Academy also only uses cribs that meet specific req:uirements specified in regulations and cribs are checked monthly to assure that they are safe. These requirements apply to all license holders that serve infants up to and including twelve months of age. Babies sleep safest on their backs. One of the easiest ways to lower a baby's risk of Sudden Infant Death Syndrome (SIDS) is to put him/her back to sleep for naps and at night. Since the recommendation to place a baby on his/her back for sleep began, the SIDS rate in the United States has dropped by more than fifty percent. Placing babies on their back to sleep is the number one way to reduce the risk of SIDS.
The following are recommendations for safe sleep for your baby:
  1. Your baby should always be put on his/her back to sleep. The back sleep position is safest and every sleep time counts.
  2. Your baby should be put to sleep on a firm sleep surface, such as a safety-approved crib mattress covered by a fitted sheet. Never place a baby to sleep on a pillow, quilt, fluffy blanket or other soft surfaces.
  3. Keep soft objects, toys and loose bedding outside of the baby's sleep area. Do not use pillows, blankets or quilts.
By signing this form I acknowledge that I am aware that placing a baby on their back has been recommended by health experts to be the safest way for babies to sleep. I am aware that placing a baby on their tummy or alternate position other than their back for sleep places the baby at a greater risk for Sudden Infant Death Syndrome (SIDS).
Directive for Alternate Sleep Position: By signing below I acknowledge that I have read the information regarding Safe Sleep and that I am directing my provider to always:
  • Place my baby on his/her stomach for sleep periods (not recommended)
  • Place my baby in an alterm1te position for sleep periods (not recommended)
  • List alternate position


Infants Information sheet

My Sleep Times

My Meal Times

The following items must be provided on the child's first day of attendance: All food, formula, water, diapers and wipes must be in original unopened store bought packaging.

Please pro4de an extra weather appropriate change of clothing. Thank you.

Preschool Age Information Sheet

School Age Children Personal Information Sheet

Safe Transportation of Food Policy

Pride Academy receives food from an outside vendor in order to provide the best possible food for the children that attend our facility. In order to keep food safe and suitable for children to eat, the following transportation guidelines are in place and met at all times:

  1. Food is brought to the facility in clean, insulated and sanitizable containers.
  2. Food is kept cold during transportation at a temperature of 41 degrees Fahrenheit or lower.
  3. Containers are clearly labeled with its contents and date of preparation.
  4. Upon receiving the food, Pride Academy shall verify the temperature of the food. When potentially hazardous food temperature is observed, Pride Academy will not accept the food.
  5. Upon accepting the food, Pride Academy shall maintain correct food temperatures until served.
I have read and fully understand the Safe Transportation of Food Policy that has been established and is maintained by Pride Academy. I take full responsibility for any matters regarding the consumption of food while my child is at Pride Academy.

Safe Conditions Policy

The following steps will be taken to ensure that your child is safe while at our child care program. Children will be actively supervised with the required number of qualified adults (adults who have completed a comprehensive crirfiinal history check, drug screen and negative TB test and have completed all required trainings).

Our child care will not care for children in areas that are being remodeled, repaired, or painted. The administrator or director is responsible for maintaining all interior and exterior surfaces, including walls, floors, ceHings, equipment, toys, furnishings, and cribs, in a safe condition, free of sharp points or jagged edges, splint􀉅rs, protruding nails or wires, loose parts, rusty parts, or materials containing poisonous substances.

The child care will take the following steps to maintain the child care:

  1. Clean the child care daily.
  2. Keep the chHd care in a sanitary condition at all times.
  3. Sanitize toys, furniture and other equipment used by children, weekly and when they become soiled or contaminated.
  4. Wash all soiled items prior to sanitization.

Transportation Safety Policy

Our child care facility does not provider transportation to school or other extra-curricular activities.

Occasionally we take field trips and parents are always invited to participate. Child/staff ratfos wilt be maintained at .all times and only Qualified staff or volunteers will be used to transport children. If children transported for field trips, you will always know prior to that day. Children will always be restrained in proper seats and seat belts.

Serious Illness Notification

If your child has any of the following, they may not return until the specified timeframe:

A.The illness prevents the child from participating comfortably in facility activities
8.The illness results in a greater care need than the child care staff can provide without compromising the health and safety of the other children or the child has any of the following conditions:

  1. Temperature: oral temperature of 101 ° or greater; Rectal temperature of 102° or greater; Axillary (armpit) temperature of 100° or greater; accompanied by behavior changes or other signs and symptoms of illness until medical evaluation indicates inclusion.
  2. Symptoms and signs of severe illness: such as unusual lethargy, uncontrolled coughing, irritability, persistent rying, difficult breathing, wheezing or other unusual signs until medical evaluation indicate inclusion.
  3. Uncontrolled diarrhea: that is, increased number of stools, increased liquid form that is not contained in the diaper, until diarrhea stops.
  4. Vomiting Illness: (two or more episodes of vomiting in the previous 24 hours) until vomiting resolves or until a health provider determines the illness to be non-communicable, and the child is not in danger of dehydration.
  5. Mouth Screen: with drooling unless a health care provider or health official determines the condition is noninfectious.
  6. Rash with fever: until a health care provider determine that these symptoms do not indicate a communicable disease.
  7. Purulent conjunctivitis: (defined as pink or red conjunctiva with white or yellow eye discharge) until hours after treatment has been initiated.
  8. Scabies, head lice or other infectious: until 24 hours after treatment has been initiated.
  9. Tuberculosis: until a health care provider or health official states that the child can attend childcare.
  10. Impetigo: until 24 hours after treatment has been initiated.
  11. Strep throat or other streptococcal: until 24hours after antibiotic treatment of fever.
  12. Chicken pox: until six days of appropriate antibiotic treatment.
  13. Pertussis: until 5 days of appropriate antibiotic treatment.
  14. Mumps: until 9 days after the onset of parotid gland swelling.
  15. Hepatitis A virus: until 1 week after the onset of illness or as directed by the health department when passive immunoprophylaxis (currently immune serum globulin) has been administered to the appropriate children and staff.
  16. Measles: until 6 after onset of rash.
  17. Rubella: until after 6 days onset of rash.
  18. Unspecified respiratory illness: severely ill children with the common cold, croup, bronchitis, pneumonia, or otitis media (ear infection).
  19. Shingles: unless the lesions can be adequately covered by clothing or a dressing, until the recommendation of a health care provider.
  20. Herpetic gingivostomatis: !"ferpes simplex, for children who cannot control their secretions.


Reason this policy is important:

The safety of children and staff must be provided in all activities of child care programs. Proper restraint systems and the correct use of them are critically important during travel to/from the child care program as well as a part of the activities of the setting.

Procedure and Practices, including responsible person(s):

• Consent for Child Care Program Activities form will be filled out for each child being transported.
• Smoking is prohibited in vehicles used to transport children.
• Children will be transported properly in a seat belt, car seat, or booster seat according to current Indiana regulations. Parents may be required to supply a booster or car seat as needed for their child if field trips involving use of transportation are a part of the program. Staff will be sure that car seats, booster seats and seat belts are used properly and each child is properly secured before setting the vehicle in motion. Staff will assist with releasing children from their transportation safety restraints, when needed. All adults in the vehicle will use proper restraining devices according to the vehicle manufacturer's recommendations.
• The number of passengers in the vehicle will not exceed the manufacturer's stated capacity for the vehicle.
• Children will be prohibited from eating, drinking, standing, or other dangerous or distractive activities during transportation.
• Children will never be left unattended in a vehicle, even for brief periods. All children will be accompanied by an adult to/from the vehicle to assure safety.
• All children will be accounted for before leaving the facility and again before returning.
• Children with special needs will h9ve their transportation plans addressed in the Special Care Plan. A staff member who is familiar with the chile's special needs will accompany the child during transportation.
• All travel routes will be planned in advance.

Vehicle Requirements

• Only insured, licensed, well-maintained vehicles will be used to transport children. 18 passenger vans are not permitted.
• Aback up vehicle will be available if needed and can be dispatched immediately in case of an emergency.
• A first aid kit and list of emergency contacts for all children and adults will be in the vehicle during transportation of children.
• A cell phone will be available in case of emergency.

Driver Qualifications

• Drivers will be Legally-licensed and shall not be under the influence of any chemical substance that may alter their ability to drive safely.
• Drivers will meet staff qualifications. Including a criminal- history check
• Drivers will be first aid and CPR certified if another staff member present is not.
• Drivers will obey all traffic regulations
• The driver shall not be included in the child: staff ratio. Drivers must not be distracted from safe driving practices by being simultaneously responsible for the supervision of children.
• The driver will be· familiar with the planned route ahead of time.
• Drivers will have evidence of a safe driving record for the previous 5 years.
• To prevent distractions, the driver is not permitted to talk on a cell phone or play loud music.

Alisia Jackson, Executive Director is responsible for collecting background checks, driving histories and updating this information yearly for those who are transporting children.
Alisia Jackson, Executive Director 1s responsible _ for ensuring the safety of the vehicle and proof of insurance for the vehicle.

When the policy applies:

This policy is in force anytime children are transported by the child care program. Staff will adhere to the policy guidelines even if no children are present when using a vehicle owned by the child care facility.

Communication plan for staff and parents:

Office/staff personnel will cover policies, plans, and procedures with all new staff (paid and volunteer) during orientation training. They will sign that they have read, understand and .agree to abide by the content of the policies.
• During enrollment this policy will be reviewed by Office/staff personnel with the parents. Parents will sign that they have read, understand, and agree to abide by the content of the policies.
• A copy of all policies will be available during all hours of operation to staff and parents in the policy handbook.
• Parents may receive _a copy of the policy upon request. A summary of mis policy will be included in the parent handbook.
• Parents and staff will receive written notification of any updates. • Parents will sign consent for Child Care Program Activities fonn for all outings where transportation is required.


• Indiana Bureau of Motor Vehicles: or 317-233-6000
• National Highway Traffic Safety Administration: or 888-327-4236
• Caring for Our Children:
• Model Child Care Health Policies -

Effective Date and Review Date

Field Trip Permission Form

Pride Academy takes great pride in allowing our children the opportunity to experiment, explore and adventure new opportunities in life. Offering field trips is one of many ways we bring this opportunity to life.

The events will include such adventures as: Roller skating., Bowling., Park and Recreation visits and much more.

Exact notice (date, time & location) will be given p(Jor to each outing.

By signing this permission slip, you are granting Pride Academy and our affiliates authorization to transport your child(ren) to and from the events.
**If you would like for your child to participate in these events, please complete, sign, and return the following statement of consent & release of liability. As parent/legal guardian you remain fully responsible for any legal responsibility which may result from any personal actions taken by the named student(s). I understand that these events will take place away from school grounds and my chi!d(ren) will be under the supervision of Pride Academy staff I further consent to the conditions stated above on participation in these events, including the method of transportation.

Pride Academy Parent Policy & Procedure Handbook

Parent Signature Page

By signing below, I acknowledge I have received a copy of Pride Academy Parent Policy and Procedures Handbook. I expect to be guided by the rules and policies contained therein. I also understand that any or all of the provisions contained in the Pride Academy Parent Policy and Procedures Handbook may be modified, amended and/ or eliminated at any time with or without notice. (Revised August 2018)

Home Language Survey

The purpose of this survey is to determine the primary or home language of the student. The Home Language Survey (HLS) must be given to all students enrolled at Pride Academy. The HLS is administered to dete􀀊e whether or not the student will qualify for additional English language development support (through the current school district). Please note the answers provided below are student-specific.

Please answer the following questions regarding the language spoken by the student:

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Consent for the use of ISTAR-KR

By: Pride Academy 5616 (Name of Agency) | School Number: E118
hereby consent to my child's participation in the ISTAR-KR (Indiana Standards Tool for Alternate Reporting of Kindergarten Readine􀃋s) assessment Use of the ISTAR-KR assessment will allow me to receive periodic reports ou the skills 1/hat my child has demonstrated in tl1e areas that build toward kindergarten readiness and eventual success in school.

I understand that any data obtained from my child's ISTAR-Iffi assessment will be stored in a secure database that is maintained by the Indiana Department of Education and also designed to be compliant With the Family Educational Rights and P1ivacy Act (34 CFRfart 99).

I understand that my chilc!l's ISTAR-KR data may be· accessed only by the program/facilizy or local education agency in which 111Y child currently is enrolled. I further understand that my child's ISTAR-KR data will be made available to any Indiana-public school that my child may attend in the future.

I understand that granting consent for the use'· of the ISTAR-I{R assessment is voluntary. I also understand that I may revoke my consent at any time but that such revocation must be in writing in order to become effective. I further understand tbat any revocation of consent shall not be retroactive and, therefore, will not apply( to IS'i'.AR-KR assessments conducted prior to the written revocation of consent


In exchange for child care services/employment organized by Prlde Academy, Inc ("Pride Academy"), of 5615 W. 22nd Street, Indianapolls, Indiana, 46224 and/or use of the property, I agree for myself and (if applicable) for the members of my family, to the following:

1. I agree to observe and obey all posted rules and warnings, and further agree to follow any oral instructions or directions given by Pride Academy, or the employees, representatives or agents of Pride Academy.

2. I recognize that there are certain inherited risk associated with the above described activity and I assume full responsibility for personal injury to myself and (if applicable) my family members, and further release and discharge Pride Academy for injury, loss or damage arising out of my or my family issues of our presence upon the facilities of Pride Academy, whether caused by the fault of myself, my family, Pride Academy or other third parties.

3. I agree to intensify and defend Pride Academy against all claims, causes of action, damages, judgments, cost or expenses, including attorney fees and other litigation costs, which may in any way arise from my or my family’s use of or presence upon the facilities of Pride Academy.

4. I agree to pay for all damages to the facilities of Pride Academy caused by my or my family’s negligent, reckless, or willful actions. 5. Any legal or equitable claim that may arise from the participation in the above shall be resolved under Indiana law.

6. I agree and acknowledge that I am under no pressure or duress to sign this agreement and that I have been given a reasonable opportunity to review it before signing. I further agree and acknowledge that I am free to have my own legal counsel review this agreement if I so desire. I further agree and acknowledge that Pride Academy has offered to refund any fees I have paid for use of services and to use it’s facilities if I choose not to sign this agreement.

7. This agreement and each of its terms are the product of an arms length negotiation between the parties. In the event any ambiguity is found to exist in the interpretation of disagreement, or any of its provisions, the parties, and each of them, explicitly reject the application of any legal or equitable rule of interpretation which would lead to a construction of “for“ or “against” a particular party based upon their status as the drafter of a specific term, language, or provision giving rise to such ambiguity.

8. The invalidity or unenforced ability of any provision of this agreement, whether standing alone or as applied to a particular occurrence or circumstance, shall not reflect the validity or enforceability of any other provision of this agreement or of any other applications of such provision, as the case may be, and each invalid or unenforceable provision shall be deemed not to be a part of this agreement.

9. Any controversy or claim arising one of or relating to this contract, or the breach thereof, shall be settled by arbitration administered by the American arbitration Association in accordance with its commercial arbitration rules, and judgement on the award rendered by the arbitrator(s) may be entered in any court having jurisdiction thereof.
10. In case of an emergency, please call
I have read this document and understand it. I further understand that by signing this release, I voluntarily surrender certain legal rights.