Enroll Now | Graceachild USA

GraceAChild USA Enrollment Form

"*" indicates required fields

The Virginia State Law requires an annual update in information. Please complete this form to its entirety!

NEW Family Referral Source:*

If a currently enrolled family referred you to our center, please share the parents full name so they may receive a $25 in-house credit. Type “n/a” if not applicable

Please select the Grace-A-Child USA location you are enrolling at:*

Christiansburg Grace-A-Child USA Academy

Radford Grace-A-Child USA Academy

Radford Summer Camp Program

Childcare Payment Assistance ~ Please choose one of the following:*

I DO NOT receive state subsidy assistance, foster care, or Swift Start assistance.

I am currently approved and receiving subsidy childcare assistance.

I am currently on the wait list for subsidy assistance. STOP! You will be responsible for ALL fees and tuition until approved.

My child is part of the foster care system.

I am currently approved through Swift Start.

Which county are you receiving assistance from:*

Montgomery County

Radford City

Giles County

Pulaski County

Floyd County

CHILD INFORMATION:

How many children are you enrolling?*

Enrollment Type:*

Date you wish your child to start: — NEW Enrollment Only!*

Where did your child previously attend childcare (please type n/a if not applicable)?*

1st Child:*

Gender First “Nickname” Last

Date of Birth:

Center Program:

2nd Child:*

Gender First “Nickname” Last

Date of Birth:

Center Program:

3rd Child:*

Gender First “Nickname” Last

Date of Birth:*

Center Program:*

4th Child:*

Gender First “Nickname” Last

Date of Birth:

Center Program:

MEDICAL INFORMATION & CONSENTS:

Virginia State Licensing requires a copy of your child’s most recent physical and immunizations, and proof of birth BEFORE a child can start. For your convenience, you may click the following link to print the “VA School Entrance Form” to have your child’s pediatrician complete as necessary: Download School Entrance Form

Pediatrician's Name:

Phone #:

Address:*

Street Address Address Line 2 City State ZIP Code

Child Illness & Communicable Disease:*

If you’re notified that your child is ill, you agree to arrange for yourself or one of your listed contacts to pick your child up within 1 hr. If your child or a member of your immediate household become ill or exposed to a Communicable Disease (CD), you agree to notify GraceAChild within 24 hrs.

If my child is ill I agree to pick them up. I will notify the center in 24 hrs if exposed to a CD.

Emergency Medical Release & Transport:*

In the event I cannot be reached, I authorize GraceAChild staff to act on my behalf for my child to receive emergency care, and if deemed necessary, arrange for emergency transport to the hospital of my choice.

I authorize GraceAChild staff to provide emergency care or hospital transport as necessary.

Not authorized – Please follow specific instructions in text box below.

Hospital Preference:*

Carilion Radford

Lewis Gale Blacksburg

Medical Care After Child Leaves the Center:*

IMPORTANT NOTE: In the event your child sustains an injury while in our care but is NOT transported to the hospital or doctor from GraceAChild’s center, you agree to contact the main office (540-382-9591) within 24 hrs should you decide at a later time to take your child to the hospital or doctor to be evaluated. Per Virginia State Licensing Standards, GraceAChild is mandated to report any medical treatment sought for the child’s injury after the child has been picked up from GraceAChild.

I agree to contact GraceAChild within 24 hrs should I seek medical care for my child after picking them up.

Allergies, Special Needs, or Medication:*

My child has no Allergies, Special Needs, or takes any Medication at this time.

Yes, I have specific details regarding my child’s Allergies, Special Needs, or Medication.

If medication needs to be administered, please click the link below to the Medicine Consent Form and have the pediatrician complete it. With the completed form, provide your child’s medicine in its original box to the director of the center. Describe any specific details in the box below.

Medication Consent (PDF)
VA Athsma Action Plan (PDF)
General Healthcare Plan (PDF)
Food Allergy & Anaphylaxis Emergency Care Plan (PDF)

Diaper Cream & Sunscreen Use Authorization:*

Product Supply & Labeling:
If you would like diaper cream or sunscreen applied to your child as needed, please provide products that are not expired, in their original box, and labeled with your child’s full name, and date of birth. Sunscreen is not required, but we highly recommend it especially between the months of April-October, and should be a minimum SPF 30.

Prescription Creams & Lotions and Possible Adverse Reactions:
If your child requires a prescription topical, we will need a Medicine Consent form from your pediatrician. If you know of any adverse reactions your child may have to diaper cream or sunscreen, please provide details in the box below.

I authorize GraceAChild staff to apply DIAPER cream

I do NOT authorize the use of diaper cream

I authorize GraceAChild staff to apply SUNSCREEN as needed.

I do NOT authorize the use of sunscreen

Specific Instructions for Emergency Medical Care, Hospital Transport, Allergies, Special Needs, Medications and/or Adverse Reactions to topicals:

PARENT/GUARDIAN INFORMATION:

If the primary parent (1st parent) has physical and/or legal custody of the child being enrolled, please be prepared to provide copies of legal court documents stating this. Please understand that if you do NOT provide this information and you choose NOT to include the secondary parent on this enrollment form, GraceAChild is legally bound to allow the secondary parent access to his/her child after we have properly identified them to do so. We can however alert you if the secondary parent is requesting to see the child.

Who does your child(ren) live with?*

1st Parents (primary parent) Relation to Child:*

First Last

Full Physical Address (PO Box is not a valid address):*

Street Address City State ZIP Code

Cell Phone #

Cell Phone Provider’s Name
(Required for emergency communication as needed)

Valid Email Address Required

Employment Status*

Va state licensing requires that we obtain your current employers address and phone # if you are currently employed.

Employed

Unemployed

Employer’s Name:

Employer's Full Physical Address (PO Box is not a valid address):*

Street Address City State ZIP Code

Employer's Phone Number:*

2nd Parents Relation to Child:*

Name:

First Last

Is the 2nd parent's physical address the same as the 1st parent?*

Yes

No. Please complete address information below.

Full Physical Address (PO Box is not a valid address):*

Street Address City State ZIP Code

Cell Phone #*

Email Address (Optional for 2nd parent):

2nd Parent Employment Status*

Va state licensing requires that we obtain your current employers address and phone # if you are currently employed.

Employed

Unemployed

Employer’s Name:

Employer's Full Physical Address (PO Box is not a valid address):*

Street Address City State ZIP Code

Employer's Phone Number:*

EMERGENCY CONTACTS & AUTHORIZED PICK-UPS:

Virginia State Law requires you to provide a minimum of 2 emergency contacts OTHER THAN the parent(s), that live within 1 hour of your child’s center.

If you are new to the area, we allow you 2 weeks to establish emergency contacts. It’s extremely important that you’re available by phone at all times while your child is in our care, especially during the 2 week period of establishing emergency contacts. If this information is not provided within 2 weeks of your child’s first day of attendance, your childcare services may be interrupted until this information is provided to the center.

1st Contact:*

Prefix First Last

Relation to Child:

Cell Phone #:

Full Physical Address (PO Box is not a valid address):*

Street Address City State ZIP Code

2nd Contact:*

Prefix First Last

Relation to Child:

Cell Phone #:

Full Physical Address (PO Box is not a valid address):*

Street Address City State ZIP Code

Would you like to include additional authorized pick-ups?*

You may add up to 2 additional people “OTHER THAN” yourself and your listed emergency contacts, who may pick your child up. This is optional.

I would like to provide 1 additional authorized pick-up.

I would like to provide 2 additional authorized pick-ups.

1st Authorized Pick-Up:*

Prefix First Last

Relation to Child:

Cell Phone #:

Full Physical Address (PO Box is not a valid address):*

Street Address City State ZIP Code

2nd Authorized Pick-Up:*

Prefix First Last

Relation to Child:

Cell Phone #:

Full Physical Address (PO Box is not a valid address):*

Street Address City State ZIP Code

Would you like to include names of Un-Authorized person(s)?*

If there are any unauthorized persons (other than parent/guardian without legal court documents) that you would like to restrict from your child, you may list them below.

I would like to provide 1 person

I would like to provide 2 people

1st Un-Authorized Person:*

Prefix First Last

Relation to Child:*

2nd Un-Authorized Person:*

Prefix First Last

Relation to Child:*

PARENTAL AGREEMENTS:

EARLY WITHDRAWAL AGREEMENT:*

We require a minimum 4 week written notice of withdrawal submitted to the center director in writing or via email. This gives us an opportunity to notify a family on our wait list that placement will be available on a given date, and also gives us an opportunity to say goodbye and prepare for your child’s departure. Failure to comply with this policy will result in a charge equal to the current weekly tuition rate for your child’s age group.

Example: If you give notice on the 1st and your child’s last day is on the 30th, this serves as a 4 week notice. However, if you give notice on the 15th and your child’s expected last day is the 30th, this is considered a 2 week notice and you will be charged an additional 2 weeks tuition to fulfill the agreement.

I Agree to comply with GraceAChild’s terms of withdrawal or pay applicable tuition fees.

LATE PICK-UP AGREEMENT:*

Pick-up after (CGAC 5:45 pm) (RGAC 5:30 pm) will result in a $10 fee for the first 5 minutes, and $5 a minute thereafter, no matter the reason! No Exceptions!

I agree to pay applicable fees if I or one of my listed contact’s fails to pick my child up by the designated time for my Center.

PHOTO CONSENT:*

Our staff loves to share photo’s on Facebook of your children engaging in fun activities, the beautiful arts and crafts they’ve created, dancing and singing, or just being plain ol’ silly nilly’s. We encourage all families to Like our Facebook page to enjoy these photo’s. We do understand the immense responsibility that comes with proper etiquette and exposure of a child, especially on social media. Therefore, all photo’s are reviewed by the center director before posting to Facebook to ensure these standards are met for each child. No child’s name is ever included in any photo’s posted. If we would like to use an awesome photo of your child for advertising purposes, we will discuss this with you ahead of time and have you sign a separate permission form.

I agree to allow photo’s of my child.

I DO NOT allow photo’s of my child.

NO PAUSE TUITION DURING CLOSINGS:*

Parents will be informed via; Email, Text Message, and/or Facebook, of scheduled closings for holidays, unexpected repairs, or in the case of dangerous weather conditions. Please note that there will be no pause in tuition, discounts or credits issued for these closings. For inclement weather days, our center will do everything possible to be open for childcare without endangering our families or employees travel to and from the center. Should we close due to dangerous weather conditions, we will notify families asap.

I understand GraceAChild’s No Pause Tuition policy.

HOLD HARMLESS AGREEMENT:*

* I understand that my child will not be allowed to play on any equipment unless my child meets the height and weight requirements.
* I understand that I am responsible for supervision while my child is playing on the playgrounds both inside and outside when I rent GraceAChild Academy USA for birthdays or special events.
* I acknowledge, release, and hold harmless the facilities, personel, and property of Graceway Ministries dba; GraceAChild Academy USA from a possible injury that could occur while my child is playing on the playground equipment.
* I release and hold harmless Graceway Ministries dba; GraceAChild Academy USA and it’s employees from liabilities and claims arising from my child’s participation on the playground equipment.

I give my permission to allow my child(ren) to play on the equipment and acknowledge the risk associated with play.

PARENT HANDBOOK:*

Grace-A-Child reserves the right to make changes to any policy, procedure, tuition rates, fees, or other processes and information in this parent handbook, rate sheets, or our enrollment forms without prior notice. We reserve this right to maintain licensing compliance, stability, and integrity of the programs, and for the safety and security of the children & families enrolled in our programs, and for the staff that our company employs. A copy of our handbook will be given to you upon receipt of enrollment.

I agree to read the Grace-A-Child Parent Handbook to be well informed.

Parent Electronic Signature for Enrollment:*

First Last

Date Enrollment Submitted:*

PAYMENT METHODS & POLICIES

GraceAChild reserves the right to make changes to any policy, procedure, tuition rates, fees, or other processes and information in the parent handbook, rate sheet, or our enrollment forms without prior notice. We reserve this right to maintain licensing compliance, stability, and integrity of the programs, and for the safety and security of the children & families enrolled in our programs, and for the staff that our company employs. A copy of our handbook will be given to you upon receipt of enrollment. The following policies are imposed to ensure consistency in all billing and collection processes with all families, and will be maintained without special regard.

* Unpaid Tuition & Late Payments ~ We require payment by auto debit ONLY. We DO NOT accept cash or checks. Payments are processed by automatic debit weekly on Thursday’s prior to the week of attendance according to our billing schedule. Should payment be returned the first time unpaid by your creditor due to Non-Sufficient Funds, we will make a second attempt to collect funds on the following Monday. If payment is returned unpaid again, you will be charged a $35 NSF fee, notified via email, and payment in full will be expected no later than Wednesday. Unpaid balances after this time may result in additional fees or suspension of care until the balance is paid.

* Late Pick-Up Fees ~ Any child clocked out of our system at 6:31pm or later WILL BE CHARGED A FEE, NO MATTER THE REASON FOR BEING LATE! (ie; vehicle breakdown, personal emergency, heavy traffic or car accidents, illness, working later than usual, etc.) Fees are as follows: $10 for the 1st 5 min’s, and $5 a minute thereafter. Auto debit payers will have their account debited automatically. For further details, please see our “Late Pick-Up Policy”.

* Reservation Fee ~ $100 per child, this fee will reserve a spot at our center for up to 6 months with or without a start date. This fee is Non-Refundable!

* Registration Fee ~ 1 child=$50, 2 children=$100, per family=$125

* Supply Fees ~ A Bi-Annual supply fee is charged in March and September: $50 per child. All fees will be debited from your credit account.

How would you like to pay your tuition & fees?*

We accept: Visa, Mastercard, Check Debit Card, or Checking Account Withdrawal (ACH). (we do not accept Amex or Discover) NOTE: *Tuition payment frequency is WEEKLY processed each Thursday before services are rendered.*

Credit/Check Card

Checking Withdrawal (ACH)

Name as it appears on the card or checking account:*

First Last

Address:

Billing Address City State ZIP Code

Phone #:*

Email Address:*

Credit/Check Card #:*

CONFIRM Credit/Check Card #:*

Expire Date:*

If your card only shows the MM/YYYY, you may just enter the last date of the month in the “DD” space.

3 digit security code on back of card:*

Name of Financial Institution:*

Routing Number:*

Checking Account Number:*

CONFIRM Checking Account Number:*

DEBIT AUTHORIZATION AGREEMENT:

Charges that may be automatically debited from your credit card or checking account will include the following as applicable:

* Registration fees (these fees are Non-Refundable)
* Weekly and monthly tuition charges
* Bi-Annual Supply Fees in March & September
* Late payment fee of $35
* Late pick-up fees, $10 1st 5 min, $5 a min thereafter
* Non-Sufficient Funds fee of $35

By typing my name below, I acknowledge that I have read the payment policies in this agreement. I understand that I am responsible for all tuition & fees that I incur upon receipt of this enrollment and while my child is actively enrolled in GraceAChild. I also authorize GraceAChild to debit due charges from my credit account provided on this form. I understand that failure to comply with said payment policies could result in applicable late fees, suspension, and/or termination from the program.

Electronic Signature for Payment Agreement:*

First Last

After clicking submit you should be re-directed to a “confirmation” screen. If you remain on the same screen, please scroll back through the form to complete highlighted areas and resubmit.