VILLAGE CARE REGISTRATION FORM
Child’s Full Name	
Birth Date:	Grade:	_____Teacher:_____________	
Parent/Guardian Full Name	
Address 	
City	State	Zip	
Phone:	Cell/Home/Work ext	 Circle One
2ndPhone#	Cell/Home/Work ext	 Circle One
Email	(Billing email? Yes/No)
Parent/Guardian Full Name	
Address (If different from above)	
City	State	Zip	
Phone:	Cell/Home/Work ext	 Circle One
2ndPhone#	Cell/Home/Work ext	 Circle One
Email	(Billing email? Yes/No)
(Next question fill out only if applicable) 
Parent/Guardian with legal custody:  Decree on file? Yes or No (circle)
Emergency Contact’s and Persons Authorized to pick up child 
Primary Emergency Contact (other than parents/guardians): Name	
Phone:	Cell/Home/Work ext	 Circle One
2ndPhone#	Cell/Home/Work ext	 Circle One
Address	City	State	
Relationship to child:	

Secondary Emergency Contact (other than parents/guardians): Name	
Phone:	Cell/Home/Work ext	 Circle One
2ndPhone#	Cell/Home/Work ext	 Circle One
Address	City	State	
Relationship to child:	

Person(s) authorized to pick up my child, besides parents/guardians or emergency contacts: Please let authorized contacts know they may be asked to present their ID.
1	
2	
3	
Emergency Release 
Consent to Emergency First Aid & Transportation: 

I hereby give my permission that my child, may be given emergency treatment by the staff of Village Care I also give permission for my child to be transported by ambulance to an emergency
center for treatment.
Parent/Guardian Signatures _________________& Date________	
Consent to Medical Care and Treatment 

In the event that I cannot be contacted immediately, medical or surgical treatment can be administered to my child in the case of an accident or emergency, as prescribed by a treating physician. Parents/Guardians
Signatures:	
Date:	

1.	Child Physician:	Phone:	
2.	Preferred Hospital:	
3.	Insurance Company:	Policy #	
4.	Regular Medications:	
5.	Allergic to any medications:	
6.	Any Allergies:	
7.	Any special health/diet conditions or things we should be aware of
Please let us know anything we need to know about your child

Please indicate which type of care you plan on using:
Weekly Care: ____
General days care is needed:
Mon.___Tue.___Wed.	Thu.	Fri.

The cost of after care is determined annually. The hourly fee will accrue to the account of any student signed into after care even if the student is only in after care for a few minutes. If a student is in a carpool and the carpool driver is late picking up, resulting in a child being signed into aftercare the responsibility for the after care cost rests with the student’s parents. Accounts not current may prohibit the student from the privilege of attending Village Care.
•	A one-time $45.00 Registration fee per child is required for enrollment. This fee must accompany the registration form, which must be completed prior to the first day of care
•	Registration Fee is waived for staff of The Village School
•	Rates are as follows:
Up to 10 hrs a month	$7.00 per hour
11-30 hours a month	$6.25 per hour
31-50 hours a month	$5.50 per hour
over 50 hours a month   	$5.00 per hour

Late Pick Up Fees:
Village Care ends at 6:00 p.m. If you are late please call  541-345-7285 Ext. 101       
There will be an additional fee of $1/ minute for late pick up and $2/minute after 6:05pm. Ex: If you are 10 minutes late to pick up that will be a $15 late fee.
Drop in care is available to registered families. Drop in care must be arranged no later than 10 am day of, provided there is space available. Drop in care use will be billed the same as regular use and billed at the end of the month.

We are a Title I school. Families that qualify for free and reduced lunch may qualify for childcare subsidies through DHS. Families are encouraged to call DHS to seek eligibility. We will gladly provide statements to anyone who needs it for an application or reimbursement. Please let us know if there is anything you would like to share with us about your child	

Behavior Agreement for Village Care
We expect that students behave in a respectful way toward their teachers, adults, and classmates and toward the property of others. Students will be approached in a dignified manner and asked to comply with the standards of behavior. If unacceptable behavior continues, parents will be informed and a plan of action will be created. In cases of continuous problem behavior, a student will be asked to not attend Village Care for a period of time, OR may not be allowed to attend altogether. 

Behaviors that will be encouraged are: 
Inside voices;
Walking feet, while indoors;
Cleanliness and responsibility in caring for toys;
Sharing and taking turns;
Kind words and gestures;
Table manners and safe eating behaviors.
Redirection will be used to guide children from behaviors that are not 
acceptable towards behaviors that we wish to encourage.

Behaviors that are not welcome are:
Teasing; 
Hitting; 
Biting
Aggressive behavior;
Threatening or disrespectful language;
Bathroom talk;
Screaming at each other (indoors)
Depending upon a child’s age, if a child’s behavior is becoming highly disruptive to the entire classroom, the child may wait in the halls until they have found their peace with a teacher, but we try to minimize these routes as much as possible.

Signature
Village Care:	Date:

Parent/Guardian:	Date:

Parent/Guardian	Date: