ST. ANDREW’S PRESBYTERIAN CHILDREN’S PLACE 2014-2015 REGISTRATION Please fill out this form accurately and completely so that we may best serve you and your child. All information must be completed using “N/A” or “none” where applicable, and your signature is required. It is your responsibility to notify us immediately, in writing, of any changes in the information you provide below. PLEASE PRINT CAREFULLY! Child’s Full Name____________________________________________ Birthdate________________________________ _________________________________________________________________________________________________ Mother’s Name Address Zip Home Phone _________________________________________________________________________________________________ Mother’s Employer Address Zip Work Phone _________________________________________________________________________________________________ Father’s Name Address Zip Home Phone _________________________________________________________________________________________________ Father’s Employer Address Zip Work Phone Mother’s Cell Phone Mother’s E-mail ___________________________ ________________________________ Father’s Cell Phone _______________________________ Father’s E-mail ________________________________ The following persons may be called in an emergency if parents cannot be reached: _________________________________________________________________________________________________ Name Relationship to Child Phone Alternate Phone _________________________________________________________________________________________________ Name Relationship to Child Phone Alternate Phone If English is not your first language, please list contact information of a person who can serve as an interpreter. _________________________________________________________________________________________________ Name Phone Number Alternate Number I understand it is my responsibility to always leave my child in the presence of a staff member. I hereby authorize the following person(s) to pick up my child. I understand that he/she will not be released to anyone else without my written permission. _________________________________________________________________________________________________ Name Relationship to Child Phone Alternate Phone _________________________________________________________________________________________________ Name Relationship to Child Phone Alternate Phone Please provide a code word that will be used to identify you on the telephone. This will only be used if you call to authorize a pick up for your child. Code word_______________________________________ ___YES___NO I hereby give permission for my child to participate in water activities provided by St. Andrew’s. Use of pools other than wading pools is prohibited. ___YES___NO I hereby give permission for my child’s home address, phone number and my e-mail address to be released in the School Directory. ___YES___NO I hereby give permission for my child to be photographed or videotaped for school wide events, brochures, newsletters or presentations for educational purposes. ___YES___NO I hereby give permission for my child’s photo, voice or student work to be used on the school website. (With your child’s safety in mind, it is our school policy to never use your child’s name on the website.) . Parent’s Signature_____________________________________ Date_______________________________ ST. ANDREW’S PRESBYTERIAN CHILDREN’S PLACE 2014-2015 MEDICAL INFORMATION Child’s Full Name_____________________________________ Birthdate__________________________ An ill child will not be admitted to St. Andrew’s Children’s Place, or parents will be notified to pick up a child, if one or more of the following exists: 1. The illness prevents the child from comfortably participating in school activities. 2. The illness results in a greater need for care than the staff can provide without compromising the health, safety, and supervision of the other children. 3. The child experiences any of the following: A. Oral temperature 100.4 degrees or greater or armpit temperature 99.4 degrees or greater, accompanied by behavior changes or other signs or symptoms of illness until medical evaluation indicates that the child can be included in the school’s activities. B. Symptoms and signs of possible severe illness (such as lethargy, uncontrolled breathing, uncontrolled diarrhea, vomiting {two or more episodes in 24 hours}), rash with fever, mouth sores with drooling, wheezing, behavior change, or other unusual signs until medical evaluation indicates that the child can be included in the school’s activities. 4. The child has been diagnosed with a communicable disease, until medical evaluation determines that the child is no longer communicable and is able to participate in the school’s activities. Please list any special problems or needs your child may have, such as allergies, existing illnesses, previous serious illnesses or injuries, any disabilities, any hospitalizations during the past 12 months, and any medication prescribed for long-term, continuous use. Children needing special care due to disabling or limiting conditions will be required to submit care recommendations from a qualified specialist prior to admission. Special Problems or Needs:_______________________________________________________________ _________________________________________________________________________________________________ Allergies:_________________________________________________________________________________________ Please initial here if there are none known: _______ In the event that I cannot be reached to make arrangements for emergency medical attention, I authorize St. Andrew’s Children’s Place to contact my child’s physician or dial 911. ____________________________________________________________________________________________________________ Child’s Physician Address Phone ____________________________________________________________________________________________________________ Hospital Address Insurance Provider _________________ Policy Number _______________ Phone Policy Holder ___________ I understand the medical information that I have provided may be viewed by administrative staff and current classroom teachers. Other than access by these individuals, medical information will be kept confidential and only released to medical personnel in the event of an emergency. Please list individuals in addition to the parents who are allowed permission to access your child’s medical records. _____________________________________________________________________________________ I hereby give consent for necessary emergency treatment when my child is in the care of this physician and/or hospital. Parent’s Signature_____________________________________ Date____________________________ 1/14 ST. ANDREW’S PRESBYTERIAN CHILDREN’S PLACE 2014 - 2015 ENROLLMENT Beginning _____________________, my child, ___________________________ will attend St. Andrew’s st (child’s name) (1 day of attendance) Children’s Place from ________a.m. to ________p.m. on the following days: (initial desired enrollment below) SCHOOL DAY 9:00 a.m. to 2:30 p.m. (September-May) 2 DAYS (Tues. & Thur.) AGE 3 DAYS (Mon., Wed. & Fri.) 5 DAYS (Mon. through Fri.) (By Sept. 1, 2014) INFANT/TODDLERS (6-23 months) EXPLORERS (2 years) EARLY LEARNERS (3 years) PRE-K (4 years) EXTENDED DAY 7:00 a.m. to 6:00 p.m. (June-May) AGE (By Sept. 1, 2014) INFANT/TODDLERS EXPLORERS EARLY LEARNERS PRE-K 5 DAYS (Mon. through Fri.) (6-23 months) (2 years) (3 years) (4 years) ENROLLMENT POLICIES         The annual Registration Fee must accompany this form. This is a non-refundable fee. All completed forms, half the Annual Supply Fee, and a deposit of one month’s tuition must be received at St. Andrew’s Children’s Place by April 14, 2014 to confirm your child’s enrollment. Your child’s class assignment will be offered to someone on our Wait List if we have not received confirmation of enrollment by this date. The Supply Fee is non-refundable. The deposit of one month’s tuition is non-refundable; however, if your child is attending the Children’s Place when you withdraw, the deposit can be applied to your child’s last month of tuition if one month’s written notice is given. Therefore, if your child is withdrawn before the end of the school year, you must give one month’s notice of withdrawal or your deposit will be forfeited. If registering after April 14, 2014, the Registration Fee, all completed forms, a deposit of one month’s tuition, and half the Annual Supply Fee must be received at St. Andrew’s Children’s Place upon registration to confirm your child’s enrollment. Refund and withdrawal policies are as stated above. Tuition is payable in advance annually, per semester, or monthly on the first day of each month. There is a $20 late fee on tuition received after the 7th of the month, regardless of holidays. The Extended Day Program is a 12-month commitment beginning in June or upon availability. If your child will not attend for an entire month at any point during the year, you may choose to pay a $300 retaining fee for each month your child does not attend rather than the extended day tuition. Any request for changes in enrollment must be submitted in writing and approved by the Registrar. Changes in enrollment are subject to availability and cannot be guaranteed. One month’s written notice is mandatory if you decide to withdraw your child from any part of our program. If one month’s written notice is not provided, your deposit will be forfeited. If you withdraw prior to the beginning of school your deposit is applied to September’s tuition. Teacher assignments, class sizes and classroom locations are subject to change. I UNDERSTAND THE ENROLLMENT POLICIES ABOVE AND AGREE TO ABIDE BY THEM. Parent’s Signature _________________________________ Date _________________________ 1/14