Avon Seedlings Program An Academic Preschool and Childcare Opportunity

Transcription

1 Avon Seedlings Program An Academic Preschool and Childcare Opportunity REGISTRATION FORM I hereby apply for enrollment of my child in the Avon Seedlings Program. Child s Gender: Date of Birth: Ethnicity: _ Address: Zip: PARENT/GUARDIAN INFORMATION Mother s Full Address: Zip: Home Phone: Cell Phone: Work Phone: Employer: Work Hours: Employer s Address: Address: Father s Full Address: Zip: Home Phone: Cell Phone: Work Phone: Employer: Work Hours: Employer s Address: Address: IMPORTANT NOTE ENROLLMENT: Prior to your child s attendance in the Avon Seedlings Program, all enrollment information must be completed, signed and returned to White Oak Elementary along with a $150 non-refundable registration fee. Please also provide a copy of your child s birth certificate, immunization records and proof of residency (for non-avon employees). Forms and fee may be turned into the receptionist on duty between 7:00 A.M. and 4:00 P.M. _ Parent Signature A receipt will be given at time of payment. Date

2 CHILD INFORMATION Please answer the following questions regarding the child you are enrolling in the Avon Seedlings Program. _ Male or Female: List siblings of child (if they attend a school within A.C.S.C., please list the school): List activities my child enjoys, favorite books, toys, etc. List activities my child dislikes: GENERAL INFORMATION 1. Independently using utensils and feeding self Yes No 2. Completely toilet trained (or will be by beginning of school) Yes No 3. Can independently put on shoes, coats, etc. Yes No 4. Requires only one quiet time/nap per day Yes No 5. Can work with other children independently Yes No 6. Is ready for organized preschool activities Yes No

3 HEALTH HISTORY SURVEY 1. Does your child have any of the following health problems? Vision problems Yes No If yes, explain Glasses Yes No Chronic ear infections Yes No Tubes in ears Yes No Hearing Loss Yes No Allergies (food, plants, etc.) Yes No If yes, explain Asthma Yes No Severe reaction to insect bites (bees, etc.) Yes No Other Health Problems? Yes No If yes, explain Please provide any additional information that will help the school make sure your child s day in the Avon Seedlings Program is the best it can be.

4 EMERGENCY AND AUTHORIZED PICK UP INFORMATION In the event of an emergency and neither parent of the child is able to be notified, below is an authorized list for emergency notification. With proper picture ID provided, all individuals listed in the emergency and authorized pick up area below have my permission to release my child to them. EMERGENCY NUMBERS: Give two local adults who could be reached during Avon Seedling hours if a Parent/Guardian is not available. First Contact: Relationship: Cell Phone: Work Phone: Second Contact: Relationship: Cell Phone: Work Phone: PICK UP AUTHORIZATION: With proper picture ID provided, person(s) authorized to pick up your child, in addition to the above names listed. Any changes must be in writing. Relationship: Cell Phone: Work Phone: Relationship: Cell Phone: Work Phone:

5 EMERGENCY INFORMATION In the event of a medical emergency, the following protocol is used: First level of intervention is action by the Avon Seedlings employee and the building level nurse and administrator. All Avon Seedlings employees are required to have current CPR and AED certification. Training is provided and paid for by the school as our first level intervention. However, we reserve the right to call 911 for assistance if at any time we deem it necessary for the safety of the child. Parent(s) will be contacted as soon as is possible. If transport is required, please indicate your preference for hospital: Child s Physician: Phone: Physician s Address: Last date of treatment before filling out this application for enrollment: _ Known allergies: Known medical conditions: _ I give my permission for transport in the case of a medical emergency. I understand that I will be liable for all charges incurred. I also understand that arriving paramedics will honor my request for hospital preference unless in their judgment another hospital should be used. _ Parent Signature Date

6 AGREEMENT TO AVON SEEDLINGS PROGRAM REQUIREMENTS Please initial and sign below. By doing this, parent agrees to adhere to the requirements and to follow all school policies and procedures. I have read and understand the requirements with the Avon Seedlings Program brochure and application packet. I understand I am submitting enrollment in the Avon Seedlings Program as my full-time child care provider for the entire school year. I will abide by the Avon Seedlings Program requirements. I will remain current in all fees due (please refer to table below regarding amount due and due dates) Number of Program Days Annual Cost Cost Minus $150 Registration Deposit/Fee Ten Month Payment Plan August May 185 $5, 600 $5,450 $ due 1 st and 15 th of each month August-May Monthly/Daily Costs $545.00/$29.46 NOTE Forms and fee may be turned into the receptionist on duty at White Oak Elementary between 7:00 A.M. and 4:00 P.M. A receipt will be given at time of payment. The first forty registration forms received will have a spot held in the Avon Seedlings Program for the school year. _ Parent Signature Date By signing this form, parents agree to make timely payments to Avon Community School Corporation to participate in the Seedlings Program. Non-payment will result in the removal of your child(ren) from the program.