Known Allergies

Yes No

If Yes please list or describe:



Emergency Contact Name Tel Name Relationship to child


Princeton Poodles (0 - 1.5 Years)
Yale Yorkies (1.5 - 3 Years)
Harvard Hounds (2.5 - 4 Months)


8AM – 6:00 PM Basic
8AM - 6:30 PM Extended Day


12 Months: September - August
12 Months: (Other)

Tour Schedule Date & Time


No Slots Available!


28 Jan 2020


29 Jan 2020


Child In Care Medical Statement

New York State

Office of Children & Family Services

To be Completed by Licensed Physician, Physician’s Assistant or Nurse Practitioner

Immunizations required for entry into day care.

Diseases 1st Date 2nd Date 3nd Date 4nd Date 5nd Date
Diphtheria, Tetanus & Pertussis (DPT) Diphtheria & Tetanus & accellular Pertussis (DTaP)
Polio (IPV or OPV)
Haemophilus influenzae type B (Hib) 4th date OR 1st date (if given on or after 15 months of age)
Pnuemococcal Conjugate (PVC) for those born on or after 1-1-08
Hepatitis B
Measles, Mumps and Rubella (MMR)
Varicella (also known as Chicken Pox)

Other Immunizations may include the recommended vaccines of rotavirus, influenza & hepatitus A

Type of Immunization Data
Immunization Details
Immunization Details 02
Immunization Details 03
Immunization Details 04
Immunization Details 05


Tuberculin Test Date :
Mantoux Results :

TB Tests are at the physician’s discretion. Acceptable tests in+clude Mantoux or other federally approved test. If possible, or if x-ray ordered, attach physician;s statement documenting treatment & follow-up

Lead Screening Date :
Attach lead level statement

Lead Screening (Include all Data & Results)

1st Year :
Result :
2nd Year :
Result :

Most recent data of lead Screening (if different from above)

Result :

Per NYS law, a blood lead test is required at 1 & 2 years of age whenever risk of lead poisoning is likely.

If the child has not been tested for lead, the day care provider may not exclude the child from child day care, but must give the parent information on lead poisoning & prevention, & refer the parent to their health care provider or the county health department for a lead blood screening test.

Health Specifics

Are there allergies? (Specify)

Is medication regularly taken?
(specify drug & condition)

Is a special diet required? (specify diet & condition)

Are there any hearing, visual or dental conditions
requiring special attention?

Are there any medical or developmental conditions
requiring special attention?


Summary of physical exam

Include special recommendations to child day care providers.

On the basis of my findings as indicated above & on my knowledge of the named child. I find that he / she is freefrom contagious & communicable disease & is able to participate in child day care.

Religious Exemptions

Public Health law section 2164 allows a child to be religiously exempted from immunization. A written & signed statement froma parent, parents or guardians of the child stating that they object of the immunization of their child due to their sincere and genuine religious beliefs should be submitted to the day care owner, operator or administrator who shall determine whether the statement of religious belief is acceptable.


Parents are always the first to be called should an emergency occur, but we ask that you also provide us with the name of 2 relatives or friends to be called in the event you cannot be reached.

Parent / Guardian #1

Parent / Guardian #2


There are several forms that make up the Little Ivies enrollment packet. Please use this checklist to help complete your child’s file and the admissions process. All forms must be in our possession before we can assume the responsibility of caring for your child. This is to ensure that your child receives the very best care possible and satisfies the record keeping requirement of state licensing guidelines. Some forms Must be renewed annually.

Admissions Application
Enrollment Contract & Security Deposit
Get to Know Your Child Q & A
Child Health Statement & Immunization Records
Emergency Contact Form
Pickup Authorization Form
Outdoor Permission Slip
Sleeping & Napping Arrangement
Infant Feeding Schedule
Sunscreen and Topicals Permission
Handbook Acknowledgement Form


Little Ivies Prep, LLC agrees to provide daycare and educational services in accordance with NYSOCFS guidelines for the 2019/20 school term. I, the undersigned, agree to pay Little Ivies Prep for services provided to my child as outlined in the below Tuition and Fee Schedule.

Registeration Fee

I understand that a Non-Refundable and Non-Transferable fee of $150 per student is due and payable at the time of registration.

Security Deposite

A security deposit in the amount of $ 3300.00 is due and payable at the time of registration to secure your child’s enrollment at Little Ivies Prep. The deposit will be equal to one month’s tuition + annual fees and will be applied to the child’s first month.
The Security Deposit Will Not Be Refunded

Tuition Rates

Tuition Rates for the 2018/19 School Term (Monday thru Friday 8am to 6pm) are as follows:

Princeton Poodles (0 – 1.5 Years)
$2800 per month
Yale Yorkie (1.5 – 03 Years)
$2800 per month
Harvard Hounds (2.5 – 04 Years)
$2800 per month

I understand that the full month’s tuition is payable, regardless of sickness, vacations, school or statutory holidays as well as snow days or closings suggested by the mayor and regardless of my child’s absence from Little Ivies Prep for any reason.

Extended Hours

Parents in need of late pick-up can do so for an additional fee

Extended PM hours 8:00am - 6:30pm
$200 additional per month

Technology & Materials Fee

An annual technology and materials fee in the amount of $350 is applied to each student and must be paid at the time of enrollment and contract renewal

Payment Options

Choose your preferred payment method:

PayPal or Stripe (convenience fee)
Credit Card (2.95% fee)

Payment Schedule:

Four payments due on the 5th Day of Dec, Mar, Jun & Sep (receive 2.5% discount)
Monthly from May 5th 2019 through April 5th 2020 (12 payments)

Late and Insufficient Funds Fee

I understand that tuition is due and payable on the 5th day of the preceding month and that a $25 late fee will be assessed on any month payment is not received by the due date. Only in such events that advanced notice is given to the director prior to the due date will the fee be waived.

I further understand tuition payments are subject to a $30 charge for checks and payments that are returned due to insufficient funds. If tuition is in arrears by 30 days or more, child(ren) may be dismissed from the school until all accounts are brought up to date or alternative payment arrangements are agreed upon by both parties.

Termination Of Contract

When enrolling; children are expected to remain in the Little Ivies program for the contract term of (12) months. Should a family choose to withdraw their child from the program early, (60) days written notice to the director is required.

If an enrolled student withdraws for any reason with proper notice during the contract year, the current and following (2) month’s charges are still due. No tuition will be pro-rated and No credits or refunds will be given.

If for any reason a child(ren) is/are withdrawn without the proper notice, I understand that no credits will be given and the remaining contract months are still considered due and payable.

Should an enrolled student withdraw prior to the first day of school, the security deposit including technology and registration fees are NON-Refundable.

Breakdown of Fees

Fees Amount
Annual Registration Fee 150.00
Annual Technology & Materials Fee 350.00
First Month’s Tuition 2800.00
Beginning Balance 3300.00
Balance Due 3300.00
Payment Recieved
Remaining Balance 0.00


In consideration thereof, and not withstanding any other terms and conditions of this agreement, I agree to be liable for payment based on the chosen options of the school program, to be paid within the first five days of the preceding month, for the complete term of the contract, regardless of program attendance, subject only to the program’s Policy on Withdrawing from Preschool, stated in this packet.

I/We the undersigned have read and understood all policies.

Parent / Guardian #1

Parent / Guardian #2


Please fill out the questionnaire below as much as you can, so that we can learn more about your child’s personality, routines at home and any medical needs your child may have. Being that children spend a large part of their day with us it is important that we understand as much about their home life as possible. All information about your child will be kept confidential and at no time will this information be released to anyone.


Sleeping Habits

  • Sleeps through the night
  • Takes Naps Easily
  • Does Not Like Naptime
  • Fussy throughout the night

Eating Habits

  • Healthy appetit
  • Big eater
  • Picky Eater
  • Likes to nibble

Health Questions

  • Does your child have allergies?

If yes, please specify to which food and/or medications he/she is allergic and what his/her reactions are when they are taken.

Does your child having any of the problems listed below?
  • A. Asthma
  • b. Frequent skin rashes
  • C. Heart Trouble
  • D.Diabetes
  • e.Frequent colds
  • F.Shortness of breath
  • g.Speech problem
  • H.Others (If not listed above, please explain.)
  • Does your child take any medications regularly?

Family Questions

  • Does the child live with both parents?
  • Is the child currently attending a day care program, play group, or independent school?


Please choose one of the following options for your infant

  • While under Little Ivies care my child will be using
  • OR

Breast Fed Infants Only

I understand that parents must provide Breast Milk daily
I understand that breast milk must be measured and labeled with child’s first name

Formula Fed Infants

I agree to provide all Formula for my infant child AND
the Formula brand name is
I (the parent) will prepare the formula prior to daycare arrival
I give Little Ivies permission to prepare formula based on package instructions

For Infants Eating Solids

  • My child is currently eating solids
I agree to provide All Solid foods for my infant child
  • I give Little Ivies permission to warm solid food

Parent / Guardian #1

Parent / Guardian #2


In the interest of the all-round development of your child, we seek your permission to take your child on nature walks, the local parks as well as field trips in the neighborhood when the weather permits. Please sign and return the permission slip indicating acceptance.

I grant permission for my child,

to go on outings and or field trips that require him/her to leave the school premises.

Parent / Guardian #1

Parent / Guardian #2


Receipt of Parent Handbook

I have accessed the 2019/2020 Little Ivies Parent Handbook detailing school policies, regulations and procedures for all students and families via the school’s website I acknowledge that I have read and am familiar with the policies and regulations set forth in the Parent Handbook. In addition, I understand that the contents of the Parent Handbook are subject to change and that any such revisions will supersede, modify, or eliminate the current contents of the Parent Handbook.

Consent to Emergency Medical Treatment

Little Ivies Prep has my consent to secure and authorize emergency medical treatment or hospitalization in the event of an accident or illness involving my child while under its supervision that, is necessary and in the best interest of my child. This authorization is granted only after a reasonable effort has been made to contact me. I understand that this written consent is given in advance of any specific diagnosis or hospital care. I agree to assume and pay for the fees for the emergency medical treatment as authorized in this statement.

Photo/Video/Audio Release

Little Ivies Prep has my consent to make (or authorize the making of) a photograph or videotape of my child or his/her work for any lawful purpose without further notice to me. I understand that such photographs, videotapes, or audiotapes of my child, which may not be accompanied by his/her name, could appear on the school’s Website on the Internet with or without my knowledge. I further understand that my child’s work, which may be accompanied by his/her name, may be electronically displayed and produced.

I have read, understand and agree to the above policies and conditions.

Parent / Guardian #1

Parent / Guardian #2


Our school policy requires that children be picked up by parents. For a child to be released to anyone other than the parents, We require prior authorization be on file and ID be presented at the time of pick up. Under NO circumstances will the child be released to anyone other than those listed below without written permission from the parent.
The following people HAVE permission to pick-up the child named above from Little Ivies Prep.
It is the parent’s responsibility to notify Little Ivies in writing of any changes to this list.

Parent / Guardian #1

Parent / Guardian #2


I, understand that my child, while under the care of LITTLE IVIES PREP will be napping on a crib OR cot within one the designated classrooms of the child care facility.
My napping child will have competent supervision at all times through, direct supervision by a caregiver who is in the same room and has direct visual contact with him/her OR an electronic monitor as an indirect means of supervision while my child is napping.
If my child is an infant, I also understand that my child will be placed on his/her back to sleep.
If my child does not take a nap, he/she will be allowed to participate in a quiet activity during the napping period.

Parent / Guardian #1

Parent / Guardian #2


Please bring the items listed below on your child’s first day of school. REMEMBER to Label all items with your child’s name.

Formula / Breast Milk and Solids
Bottles and Sippy Cups
Diapers and Wipes (At least 8 diapers should be brought in daily)
2 sets of extra clothes including onesies and socks
1 Crib Sheet & 1 Light Blanket
Breakfast, Lunch and 1 Snack
Pull-ups & Wipes
1 set of extra clothes including underwear and socks
2 Toddler Sheet & 1 Light Blanket
Breakfast, Lunch and 1 Snack
1 set of extra clothes including underwear and socks
1 Toddler Sheet & 1 Blanket