Huckleberry Cheesecake, Inc.

The New Generation of Child Development

Registration Form

Application Date:_________________ Desired Start Date:______________

Child’s Name:__________________________________________________________

(Last) (First) (Middle) (Nickname)

Age:_______ Date of Birth:_______ Sex:______ Lives with:_________________

Home Address:_________________________________________________________

No. Street City State Zip

Home Phone:_____________ Number of Siblings:______________ Ages:__________

Parent/Guardian Information

FATHER

Name:_________________________ Employer:______________________________

Business Address:______________________________________________________

Home phone:___________ Office phone:____________cellular Phone:_______________

MOTHER

Name:_________________________ Employer:______________________________

Business Address:______________________________________________________

Home phone:___________ Office phone:___________cellular phone:________________

GUARDIAN

Name of person(s)/agency having legal custody, if not parents:____________________Phone:______________

Relationship:_______________________ Address:____________________________________

Name of person to contact if parent cannot be reached:________________Phone:____________

Relationship:_______________________ Address:____________________________________

2001 M Street, NW Email hci4@erols.com Phone # (202)467-4202

Washington, D.C. Fax# (202)467-4129

Persons Authorized to Pick Up Child/Visit Center

Name Day Phone Relationship

____________________ _______________________ ____________________

Authorization for Emergency Medical Treatment

In the event that my child becomes ill or involved in an accident and I cannot be contacted, I authorize the following hospital or physician to provide required medical emergency medical treatment:

Hospital:__________________________________________________________________________________

Address:____________________________________________________________ Phone:________________

Physician:__________________________________________________________________________________

Address:____________________________________________________________ Phone:________________

I give Huckleberry Cheesecake permission to transport my child for such care or to seek professional transport service. I accept responsibility for any necessary expense incurred in the medical treatment of my child which is not covered by the following health insurance:

Health Insurance Company:___________________________________________________________________

Policy Number:________________________________________ Type of Coverage:______________________

Child’s known allergies or physical conditions:___________________________________________________________________________________________________________________________________________________________________________

Authorization for Field Trips/Outing Participation

I give my permission to include my child on any field trips or outings which may be taken in conjunction with Huckleberry Cheesecake programs. I understand that such field trips and outings may involve the use of public transportation, and that I will be notified of such field trips or outings in advance.

I understand that it is part of Huckleberry Cheesecake’s programs that all children participate in some form of outdoor activity daily, weather permitting.

Non-Solicitation

The Parent shall not from the date of this contract until one year after expiration of this contract solicit or induce any employee of Huckleberry Cheesecake to leave the employment of Huckleberry Cheesecake to perform full-time services for the Parent.

I hereby contract to enroll my child,___________________________as a student of Huckleberry Cheesecake beginning on the __________ day of ________________, ____.

In contracting for the enrollment of my child, I understand and fully accept and agree with the following terms of this Tuition and Enrollment Agreement:

A. Tuition of the current calendar year is $_____________per month

B. A Security Deposit equal to one month’s tuition is due in full upon enrollment. The

Security Deposit will be applied to my child’s LAST month’s tuition, PROVIDED

that Huckleberry Cheesecake has received written notification of withdrawal no later

than the first day of the month PRECEDING my child’s withdrawal date.

C. There is an annual non-refundable Registration Fee of $___________.

D. There is a $50.00 bounced check charge for each check tendered in payment of any fee which is dishonored by the payer’s bank.

E. Tuition is due BY the first day of each month. A fee of $15.00 per day is charged for late payment. An account which is fifteen (15) days in arrears may result in dismissal of the child.

F. There will be NO tuition refunds for days my child missed due to illness, vacation, or any other reason.

G. Huckleberry Cheesecake may terminate your child’s enrollment upon 30 days notice if the following conditions arise.

a) In the judgement of Huckleberry Cheesecake’s director, the child’s behavior threatens the physical or mental health of other children in the center.

b) In the judgement of Huckleberry Cheesecake’ director, the Center’s program does not meet the developmental or special needs of your child.

Signature

In signing this Registration Form and Enrollment and Tuition Agreement, I affirm that I have read and understand its contents and agree to be bound by it provisions.

_________________________________________ ___________________________

Signature (Parent or Guardian) Date

______________________________________________________________ _________________________________________

Signature (Parent or Guardian) Date