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Our Schools

  • School and Child Information
    • School:
      select

      Child's Name:
              		Nickname:
      Date of Birth:
              		Sex:
       

  • Mother/Father/Guardian Information

    • Mother/Father/Guardian Information
      (List only individuals who have legal custody of child. If mother is not listed, or if guardian is not a parent, legal proof of custody must be provided.)

      Name:
              		SSN:
      		 Home Address:
       
      City:
              		State:
      select
      		Zip:
       
      Home Phone:
              		Cell Phone:
      		 Work Phone:
      Employer:
      		 Email Address:
               		Employer Address:

      Mother/Father/Guardian Information
      (List only individuals who have legal custody of child. If mother is not listed, or if guardian is not a parent, legal proof of custody must be provided.)

      Name:
      		 SSN:
      		 Home Address:
      City:
      		 State:
      select
      		Zip:
      Home Phone:
      		 Cell Phone:
      		 Work Phone:
      Employer:
      		 Email Address:
      		 Employer Address:

  • Emergency Contact Information
    • Persons authorized to pick-up the child daily:
       
      Persons to be contacted in case of illness, accident or emergency and authorized to pick-up the child from the school if the parents or guardians cannot be reached (Minimum of 2 required)
      Name:
              		Address:
       
      Phone:
              		Relationship:
       
      Name:
              		Address:
       
      Phone:
              		Relationship:
       
      Child's Physician:
              		Phone:
       
      Child's Dentist:
              		Phone:
       


      List allergies and intolerance to foods, medications, or other substances [Type "n/a" if none]

       
      Actions to be taken: [Type "n/a" if none]  


  • Authorization for Emergency Medical Care
  • Photo Release

    • Photo Release

      I give permission for photos of my child to be used by Minnieland Academy, for purposes to include but not limited to Constant Contact Emails and Newsletters, the Minnieland website, social media, ads, flyers, brochures, videos and for other marketing purposes.
      I do not wish for photos of my child to be taken and used for any of the above purposes.
      Signature of Parent/Guardian:
              		Date:
       

  • Child's Profile

    • FAMILY

      Mother's Occupation:

      Father's Occupation:

      Our family members (bothers, sisters, grandparents, etc.) living at home:

      NameAgeRelationship

      Other family members living in this community:

      NameAgeRelationship

      HEALTH

      What communicable diseases has the child had?

      Other:
      Any chronic physical problems?
      Type of accomodations needed:*
      Any developmental or learning needs?
      Type of accomodations needed:*
      *If special accomodations are needed, a current copy of the child's IEP or ISP is required.

      MEDICATIONS

      Are any medications given regularly? (Please list medications and reason)
      select


      Brand of infant formula (if applicable):

      Please Note: It is in Minnieland's policy to feed infants on demand unless other written instructions are on file from the child's physician.

      SPEECH

      Describe your child's speed:

      TOILETTING

      Does your child have any special needs?
      select

      If so, please explain:

      SLEEP PATTERNS

      What time does your child go to bed? Awaken?
      Does he/she walk, talk, cry out at night?
      select

      Does he/she take anything to bed with them?
      What is his/her mood upon awakening?
      Does he/she take naps:
      select
      Typical time of nap?

      INTERESTS

      Has he/she had experience playing with other children?
      With what age child does he/she prefer to play?
      What are his/her favorite activities at home?
      Does he/she like to:

      Can he/she ride a tricycle?
      select

      Has he/she had experience with:

      SCHOOLING

      Please list any previous school and/or child care center enrollment:

      School/CenterCity/TownStateDate

      Is your child attending another school concurrently with our program?
      select

      Name of School:
      Grade of Class Level:



  • Comments
    • In what particular ways can we help your child this year?

      Describe your child briefly (personality, abilities, etc)



  • Financial Agreement
    • I (please print name), the parent/guardian of agree to pay my child's tuition no later than Monday of the current week. If i have not paid by Wednesday of the current week, I understand that I will be charged a late fee. I also understand that if I do not pick my child up by the centers closing time, I will incur a charge of $1.00 per minute. In the event that my child's tuition account becomes two weeks in arrears, I understand that my child care services with Minnieland will be terminated. I also agree to pay all costs and expenses including, without limitation, court costs and reasonable attorney fees incurred by Minnieland Private Day School, Inc. in connection with the collection of tuition and the enforcement of this agreement.

      Parent/Guardian Signature Date
  • Hold Harmless Agreement
    • I (please print name), the parent/guardian of agree to release and hold harmless Minnieland Private Day School, Inc. and its employees, from any accident or harm that may occur should I retain services of any Minnieland employee for the care of my child(ren) outside the child care center. I understand that Minnieland Private Day School, Inc. does not condone or encourage its employees to babysit for parents of enrolled children outside of the child care center. If I retain the services of any Minnieland Private Day School, Inc. employee in such capacity, Minnieland Private Day School, Inc. has no responsibility and is held harmless from any incident which may occur.

      Parent/Guardian Signature Date
  • Minnieland Policies
      1. I understand that my child must not be left on school grounds without supervision. I agree to walk my child into the school each morning and release my child to a teacher before leaving my child.
      2. I understand that all required forms must be completed and on file at the center before my child may attend.
      3. I understand that no child may be released to anyone except parents/guardians without written permission. I understand that Minnieland will release children to either parent unless a court order indicating sole custody is provided to the center Director. I agree to give the center a list of all persons authorized to pick up my child.
      4. I understand that no medication will be administered without written permission from parents.
      5. I agree to support and reinforce the schools rules and procedures that concern the health and safety of my child and other children
      6. I understand that the Director will notify me whenever my child becomes ill and I agree to pick-up my child or make arrangements to have my child picked up by and authorized individual within one hour of notification.
      7. I understand that my child cannot attend the school if he/she has any illness that threatens the health of other children. I understand that Health Department regulations concerning periods of infection will be enforced. I understand that my child must be fever and symptom free for 24 hours before returning to school after an illness. I also understand that prescription medication must be administered to my child at home for 24 hours before he or she can return to school.
      8. I understand that I am required to inform the center within 24 hours of the next business day if my child or any member of my immediate household has developed any reportable communicable disease, as defined by the State Board of Health, except for life threatening diseases which must be reported immediately.
      9. I understand that child care services may be terminated for any of the following reasons:
        1. My child's tuition account becomes more than two weeks in arrears.
        2. Failure to respond in a timely manner when contacted by the center to pick my child up when he or she is sick.
        3. Failure to adhere to the 24 hour illness recuperation period.
        4. Failure to notify the center, in advance, if my school age child will not be attending after-school care.
        5. Failure to provide the center with up-to-date emergency contact information for my child.
        6. Minnieland does not receive parental support and help if my child is found to have a learning or behavioral problem. This includes failure to attend parent conferences, and to follow through with medical and/or educational specialists.
        7. My child's behavior pattern threatens his or her own health and safety or threatens the health and safety or other children and staff.
        8. Parents/guardians are no longer supportive of Minnieland's programs and philosophy and become negative and uncooperative in their actions and opinion which may undermine the operation of the school.
        9. Parents who are repeatedly late will be asked to make other child care arrangements.

      PLEASE READ AND SIGN:

      I have read the policies in the Minnieland Parent Handbook and understand their application to me and my child.
      Mother/Guardian Signature Date:
      Father/Guardian Signature Date:
      Director's Signature Date:

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Minnieland Academy • 4300 Prince William Parkway • Woodbridge, Virginia 22192 • 703-680-2548 • 800-504-2993
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