ECEC Office Forms

Please return your completed form one of the following ways:

  • Drop off at the ECEC Front Desk Office
  • Mail: 18501 Rotunda Drive, Suite 300, Dearborn, Michigan 48124
  • Email*: 
  • Fax: 313-583-1185

*The University of Michigan-Dearborn Early Childhood Education Center (UM-Dearborn ECEC) does NOT accept sensitive personal information via email such as banking information.

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Child Information Record (Emergency Card)

Child Information Record Form

This form is provided through the State of Michigan Department of Licensing and Regulatory Affairs - Child Care Licensing.  A form is required for each child in the care of UM-Dearborn's ECEC.  This form must be updated if a change occurs or annually.  Emergency Contacts and Release of Child permission is included on this document.  Only individuals listed on this form are permitted to pick up the child.

Per Licensing, the form must be completed in its entirety.  If an answer is unknown or does not apply, type: "unknown" or "none".  ECEC policy requires the Child Information Record to be typed and will not accept handwritten records.  If you are unable to complete this form on your computer, please stop by the ECEC Office and a computer will be made available for your use.

Policies & Agreements

Policies & Agreements Form

The ECEC policies and agreements are updated annual with enrollment.  This include: Mutual Respect Policy; Permission for Developmental Assessment; Written Information Packet Documentation; Nutrition Policy; Audio-Visual Permission; Pesticide Notification; Parent Handbook/Health Policy Agreement; Parent Notification of Licensing Notebook; Consent and Waiver of Liability; Agreement to Financial Obligation.

Tuition Payment ACH Debit Form

ACH Debit Form

The ACH (automated clearing house) Debit Form is used to set up an electronic draft for tuition payment.  The form must be accompanied by a blank voided check/draft or a letter from your banking institution including account and routing numbers.

New enrollments must be set up prior to the 15th day of the month for the next months payment.

This form must be mailed, faxed or dropped off at the ECEC Office.  The University of Michigan-Dearborn does not accept sensitive personal information, like banking information, through email.

Health Appraisal Form (Physical Form)

Health Appraisal Form

The Health Appraisal and Immunization Records are required per Michigan State Licensing.  This information is requested so that the school can work with the parent to meet the physical, intellectual and emotional needs of the child.  Parent/Guardian must complete Section I.  Section II must be completed by a doctor, nurse or dentist.  Section III may be certified by the transcription of information from the certificate of immunization.

The ECEC requires this paperwork to be complete and on file with application to program and no later than the first day school.  Physical must be done within the last 6 months for toddlers, and within last year for preschoolers.  Records must be updated annually for children under 3 years of age, and every two years for children over 3 years of age; date for updating is based upon current record on file.  

FERPA Disclosure

FERPA Disclosure

The Family Education Rights and Privacy Act of 1974 is a federal law that protects the privacy of student education records.  Health Appraisal Reports, Immunization Records, and weekly communicable disease reports are all considered part of your child’s student education records.  Reports recorded to the local health department all require voluntary consent from the parent or legal guardian for reporting.  MDHHS considers consent received unless written notification to object reporting is issued from the parent or legal guardian.

To ensure that all families understand these rights, the University of Michigan-Dearborn Early Childhood Education Center (ECEC) requires explicit permission to share this information.

Petition Form

Petition Form

The Petition Form is utilized for change in schedule, exception to a policy and to withdrawal.  Please fill out the child's information, parent/guardian information with email along with the section(s) needed and the justification.  This can be turned into the front desk directly or email to  Please allot for 30 days' notice when submitting a request.

The Early Childhood Program Committee meets twice per month and petitions are reviewed at those meetings.  Responses will be emailed with a copy of the petition and an adjusted statement if applicable.

Contract of Service

Sample of Contract of Service

The contract of service is a document signed by the parent/guardian, noting the days and hours service will be provided and the cost of service on a monthly basis. Families can choose a minimum of two full days a week up to five full days a week. The fee is based on enrollment terms and age of the child. The term of contract is for the entire school year.
Reservations for fall enrollment must be accompanied by $225 (check, money order or certified check). The ECEC reserves the right to disenroll a family for not following proper procedures to ensure they have an enrollment space for fall. As a student of UM-Dearborn, understand that you will have a hold on your account which means that you will not be able to register for classes or acquire your transcript until all outstanding fees and charges due to the University’s Early Childhood Education Center are paid.

Early Childhood Education Center

Early Childhood Education Center (ECEC)
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