THE FAMILY OF FAITH PRESCHOOL REGISTRATION FORM

Transcription

1 THE FAMILY OF FAITH PRESCHOOL REGISTRATION FORM The Family of Faith, FM 529, Houston, TX 77095, Phone Fax Web Site: CHILD S AGE (Office use only) (on Sept.1,2014) DAYS 18 mo. - 2 yrs. TTh MWF M-F 2 yrs. TTh MWF M-F 3 yrs. TTh MWF M-F 4 yrs. TTh MWF M-F # in order of receipt Date rec ved Enrollment date Fee Date Received Amount Cash or Check Receipt or Check Number Registration Child Information: Tuition Name Sex Present Age Age on September 1, 2014 Birth date Nick name Special needs/allergies * (*Must complete our Life Threatening Allergy Release Form. ) Program Indicate 1 st, 2 nd, 3 rd Choice 2 day 3 day 5 day My child s starting date will be. Parent Information: Name of Parents Address City State Zip Parent/Legal Guardian Contact Information: Home Phone address Dad Work Dad Cell Mom Work Mom Cell

2 FEE SCHEDULE School Year A MINISTRY OF THE FAMILY OF FAITH FM 529 Houston, TX Phone: FAX: Our team of dedicated preschool educators and child care caregivers are committed to teaching your preschool child with loving care in a nurturing environment where they feel safe and happy! The hours are from 9:00 a.m. 2:00 p.m. We offer a short schedule for the 18 months 2 yr. olds. Ask to see those rates. We offer extended hours for an additional fee. Ask to see the extended care form. Registration Fee: (non-refundable) due at registration $ per child $ for second and subsequent children Annual Capital Use Fee: $100 per child Monthly Tuition Payments for 18 mos.-2 yrs (Panda/Monkey Room) 2 days per week $ days per week $ days per week $ Monthly Tuition Installment Payments for 3 yrs. Pre-Kindergarten 2 days per week $ days per week $ days per week $ Tuition is due on the 1 st day of class, each month. NOTE: For greater savings, tuition may be paid by the semester or by the year. Details in Parent Handbook. Also, ask about a 12 month plan. Multi-Child Discount: Families with more than one child enrolled receive a 10% discount on tuition for the second and subsequent children.

3 THE FAMILY OF FAITH ENROLLMENT RECORD The Family of Faith, FM 529, Houston, TX 77095, Phone Child s Full Name Sex Name Child is Called Present Age Birth Date Home Address City Zip Home Phone Subdivision Ethnicity Mother s Name Occupation Home Address Home Phone City, State, Zip Business Business Phone Cell Phone or Pager Mother s Driver s License # Father s Name Occupation Home Address Home Phone City, State, Zip Business Business Phone Cell Phone or Pager Father s Driver s License # Parent Status: Married Unmarried Divorced Separated Widowed If parents are separated or unmarried, who has custody of the child? Are there any restrictions? Church affiliation: Mother - Member of a church Y / N Where Father - Member of a church Y / N Where Has child been baptized? Y /N Names and ages of brothers and sisters When your child is brought to school, he will be left in the presence of a staff member. Please list persons whom yo approve to pick up your child and leave our facility. Your child will not be released to others without your specific permission. PLEASE NOTE: For your child s safety, we will ask to see this person s driver s license.

4 MEDICAL RECORD (PHYSICIAN S SIGNATURE REQUIRED ON BOTHPAGES School Year THE FAMILY OF FAITH PRESCHOOL A MINISTRY OF THE FAMILY OF FAITH FM 529 Houston, TX Phone: FAX: Name of Child Birth date Name of Physician Physician s Phone Address City Zip Health Requirements: This facility must have, on file, evidence that each child is physically able to take part in the preschool program, within one week of admittance. Name of Child does / does not have food allergies. The child s allergies are as follows: Name of Child has been examined by me within the past 12 months and is physically and mentally capable to participate in your program. CHILD S LAST EXAM DATE Signature of Physician Date Please attach a current copy of the child s immunization records to this form. This facility must have on file the dates (month, day, year) and the number of doses for each type of immunization received. If the immunizations are not current, the immunization cycle must be completed as soon as medically feasible and a note from the doctor to that effect must be put into your child s folder. SPECIAL SENSES SCREENING RECORD* BY PHYSICIAN / SCREENER Visual acuity and hearing sensitivity screening are required for 4 year olds enrolled in preschool. Rescreening is only required if an abnormality was noted on the first screening. VISION TEST RESULTS HEARING TEST RESULTS Right Eye: Left Eye: Y = Response N = No Response Pass Fail Pass Fail Examiner s Signature: (or attach a copy of child s vision results) Right Ear (Hz) Left Ear Pass Fail Pass Fail Examiner s Signature: (or attach a copy of child s hearing test results) *PLEASE NOTE: BY STATE LAW all children four years old by September 1 must have vision and hearing screening, the results of which must be reported to the state by the school. This screening may be done by your physician and recorded on this form or through the school at a cost of approximately $10-15.

5 THE FAMILY OF FAITH PRESCHOOL MEDICAL RECORD PAGE 2 1.) If your child has had chicken pox, please complete the statement: My child had varicella disease (chicken pox) on or about (date) and does not need varicella vaccine. Physician s Signature Date Parent/Legal Guardian s Signature Date PLEASE NOTE: Varicella (chicken pox) vaccine is not required if your child has had chicken pox disease. 2.) As required by the Texas Department of State Health Services, each child at an appropriate age shall be immunized against diphtheria, tetanus, poliomyelitis, mumps, rubella, rubeola, pertussis, Haemophilus influenza type b, varicella, hepatitis B, invasive pneumococcal and hepatitis A disease. It is noted that the invasive pneumococcal and hepatitis A vaccines were added by law in September of ) Please attach a current, signed, copy of your child s shot record. PLEASE NOTE: If your child is scheduled to have shots within the year, please make note of this with your scheduled time so we can have it on file for our records. Be sure to tell the administrative staff when you return your completed papers. 4.) If there are any other reasons why your child is not vaccinated, please document your reasons and attach the paper to this form. Be sure to tell the administrative staff when you return your completed papers. This form is due by the first day of school. By law we are required to have this form. Please prepare this ahead of time. Thank you! If you were enrolled last year, then have the updated shots available on a separate sheet of paper. PLEASE NOTE: The State of Texas requires that all of your child s immunizations must be updated and kept current throughout the entire school year

6 TREATMENT FOR MINORS CONSENT FORM School Year Sign both sides in the presence of a Notary THE FAMILY OF FAITH PRESCHOOL A MINISTRY OF THE FAMILY OF FAITH FM 529 Houston, TX Phone: FAX: AUTHORIZATION FOR EMERGENCY MEDICAL CARE In case of emergency, please accept this letter as authority to treat my child whose name is listed below in the event that I cannot be reached at the time of illness or accident: Child s Full Name Birth Date Allergies: Medication Food Environmental/Other Regularly Administered Medications I/We being the parent(s) or legal guardian(s) of the above named minor do hereby appoint the following individual(s) to act in my behalf in authorizing medical, dental, surgical care and hospitalization for the above named minor in the event I cannot be reached. (Please list persons to call in an emergency if the parents cannot be reached. Please do not list the name of a close friend who is likely to be with you when you are away from home. Also, be certain that the names you list are willing to pick up your child at school in case of an emergency.) Name Relationship Phone(s) Name Relationship Phone(s) Father s signature Date Mother s signature Date Legal Guardian(s) Date (Both parent(s) and/or Legal Guardians must sign unless the court has appointed custody to one parent.) In case of an accident or serious illness, I request the school authorities to contact me or those people listed above. If we cannot be reached, I hereby authorize the school administration to call the physician listed below: Physician: Name Address Phone If you are unable to contact him/her, I authorize the teacher and/or administration of Faith Academy to arrange all necessary medical services for my child on my behalf. In case of emergency, I also give my consent for (child s name) to be transported and supervised by The Family of Faith Preschool s staff. I hereby release any adult, helper, or driver from any liability and any and all claims from any injury which might be received during this trip, whether at the destination or in traveling to or from said destination. Please accept this letter as your authorization to use the doctor on call in the emergency room of the following hospital for any necessary medical treatment. Hospital: Name Address Phone (If no hospital preference, write NEAREST. ) Name of parent s insurance company Group # Identification # I give permission to the emergency physician to secure proper emergency treatment and to order injection, anesthesia, or other emergency treatment if I (we) cannot be contacted. It is understood that a conscientious effort will be made to locate me or my spouse, before action is taken. But if it is not possible to locate us, I accept the expense. In the event of life-threatening emergency, I understand that 911 will be called to take my child to my preferred hospital that is listed above, if possible, or to the closest available facility. (Sign only in presence of a Notary) Parent or Legal Guardian s Signature: Subscribed and sworn to, before me, this day of 20. Notary Public Signature:

7 MEDICAL EMERGENCY INFORMATION FORM School Year Sign in the presence of a Notary THE FAMILY OF FAITH PRESCHOOL A MINISTRY OF THE FAMILY OF FAITH FM 529 Houston, TX Phone: FAX: Child s Name Birth Date Home Phone Parent or Guardian s Name Address Street City/State Zip A child who appears ill upon arrival will not be admitted to class: TEXAS DEPARTMENT OF PROTECTIVE & REGULATORY SERVICES (TDPRS) REQUIRES THAT CHILDREN BE FREE OF FEVER, VOMITING, AND/OR DIARRHEA FOR AT LEAST 24 HOURS BEFORE RETURNING TO SCHOOL. Our Center is not able to meet the needs of sick children. Please Note: The parent should authorize the physician (at the time of registration) to accept a call from The Family of Faith Preschool for emergency medical care. Health History (Use another sheet if necessary) Has this child: an existing illness(es)? Yes No If yes, please name: had previous injuries? Yes No If yes, please describe: had hospitalizations during the past 12 months? Yes No If yes, please describe: any allergies (medicine,food,other) Yes No If yes, please list: Are there any parent concerns or medical information that we should know about? Yes No If yes, please describe or use another sheet of paper: Please check any of the following that your child has had: Rheumatic Fever Asthma Convulsions Chicken Pox Epilepsy Rubeola Rubella Diabetes Mumps Hay fever Other Has your child had surgery? Please explain Any surgery, accidents, serious illnesses, or handicapping problems? Please explain Is your child taking medication prescribed for long-term continuous use? Please list: What is your child s present general physical condition? Have you noticed a hand preference? Right Left Not Observed CONSENT FORMS 1.) WATER PLAY: Circle one - I give/ I do not give consent for (child s name) to participate in the following water activities: Water Table Play Splashing/Wading Pools Sprinkler Play 2.) PHOTOGRAPHIC RELEASE: Circle one - I give/ I do not give permission to The Family of Faith Preschool to photograph and/or videotape my son/daughter, and use the resulting photographs/videotape for any lawful activities for the purpose of promoting the preschool to the public or for preschool child care programs and curricular activities. I relinquish all rights, titles, and interest in the finished photographs, negatives, and videotape film. 3.) DIRECTORY RELEASE: Circle one - I give/ I do not give permission to The Family of Faith Preschool to include the following in the Intra-School Directory my child s name, parent s name, address, phone number, address (for purposes of school parties and activities only). (Sign only in presence of a Notary) Parent or Legal Guardian s Signature: Subscribed and sworn to, before me, this day of 20. Notary Public Signature:

8 THE FAMILY OF FAITH PRESCHOOL LIFE THREATENING ALLERGY RELEASE FORM The Family of Faith, FM 529, Houston, TX 77095, Phone A life-threatening allergy is also referred to as Anaphylaxis. Anaphylaxis is the word used for serious and rapid allergic reactions usually involving more than one part of the body which, if severe enough, can kill. The Family of Faith Preschool is not a peanut free environment since we share space with The Family of Faith Lutheran Church and we have no control over the congregational, youth, or children s activities throughout the week or on weekends. Even though we thoroughly clean and supervise children during snack time and lunch, we may not be aware of possible allergens that may be in the area. As stated in our Parent Handbook, the medication policy for The Family of Faith Preschool reads as follows: Medication Policy: If your child requires medication while at school, you MUST come to the Director s office, fill out a medication sheet explaining when to give it and giving us permission to give it. If your child requires an epee pen due to severe allergy issues, again you must come to the office and inform the Director and fill out the correct form. Please acknowledge receipt of this form, fill out the information below, sign, notarize, and return to our school. My child has allergies to They are/are not (circle the appropriate answer) life-threatening. It is/is not (circle the appropriate answer) necessary for my child to receive any type of medication for this allergy. Please call me if there is an emergency. I have read this form and I understand that no medication can be administered to my child unless I fill out the proper form. I also understand that the staff of the preschool will do everything in their power to prevent my child from things he/she is allergic to. However, they might be unaware of events or happenings in the church that might have produced possible allergens that my child may react to. (Sign only in the presence of a Notary) Mother s Signature: Father s Signature: Subscribed and sworn to, before me, this day of, 20. Notary Public Signature: