Enrollment Application - smokerisenurseryschool.org

Smoke Rise Cooperative Nursery School
38 North Road
Kinnelon, NJ 07405
(973) 838-9088
Enrollment Application
Please complete all information (Addresses, Phone #'s etc..)
Please Circle:
Child's Name:
3AM
4AM
Birth date:
Date of Enrollment:
Nickname:
Address:
Mother's Name:
Father's Name:
Home Address:
Home Address:
Home Phone:
Home Phone:
Cell Phone:
Cell Phone:
E-Mail Address:
E-Mail Address:
Employer:
Employer:
Address:
Address:
Work Phone:
Work Phone:
Childs's Doctor:
Address:
Phone:
Persons authorized to pick up child/and or contact in case of Emergency:
Name:
Name:
Relationship:
Relationship:
Address:
Address:
Phone:
Phone:
Cell Phone:
Cell Phone:
....
: SECTIONS- TO BE COMPLETED BY PfiREfJT(S)
(First)
Gender
D Male D Female
If Yes, Name of Child's Health Insurance Carrier
Child's Name (Last)
^
Endorsed by:
American Academy of Pediatrics, New Jersey Chapter
New Jursgy Academy of Famity. Physicians
New Jersey Department of Health and Senior Services
UNIVERSAL
CHILD HEALTH RECORD
_....,,,.,„,....,.. __
Does Child Have Health Insurance?
DYea
DNo
Parent/Guardian Name
Parent/Guardian Name
Da e of Birth
Home Telephone Number
Work! elephone/Cell Phone Number
Home Telephone Number
Work! elephone/Cell Phone Number
/g/ve my consent for my child's Health Can Provider and Child Care Provider/School Nurse to discuss the Information on this form.
Signature/Date
This form may be. released to WIG.
QYes
QNo
::.';:.
.. .. .
. ..
.:;
;;.^,v.
i -. .. . .
SECTION It- TO BE COMPLETED BY HEALTH CAREPROVIQER
;
; :
:
:
Date of Physical Examination:
AbnormaBties Noted:
QYes
Results of physical examination normal?
WeighVrnusf be faken
within 30 days for WlC)
i
IMMUNIZATIONS
Chronic Medical Conditions/Related Sufseries
• List medical conditions/ongoing surgical
concerns:
Medjeations/Treatmenls
: * List medications/treatments:
Limitations to Physical Activity;
: « List: limitations/special considerations;
within. 3Q days: for WIC)
Head ClrctimferBnce
(if <2 Years) .,'
Blood Pressure
(If >3 Years)
••„-: ..
"~^
QNO
Qlmrjttinlzatlon Record Attached
DDate NextJfnmunlzatfon Pue:
MEDICAL CONDITIONS
Comments
DNone;
E]Special;Care Plan
Attached
Cohirnenfi
DNpne
QSpedalCare Plan
Attached
. Comments
QNone
QSpeclarCare
Plan
:
Comments
QNIbha
QSpedahCare Plan
•• i
Attached
Comments
QNone'
Allergies/Sensitivities
QiSpecial^Care
Plan
• List allergies:
Attached
Comment's
QNone
Special Oiet/v1tamln& Mineral Supplements '
DSpedal: Care Plan
• List dietary specifications:
. Attached
Comments
Behavioral Issues/Mental Health Diagnosis
QNone
.
• List behavioral/mental health
DSpedal Care Plan:
Attached
issues/concerns;
Comments
Emergency Plans
DNone
OSpeclal Care Plan
• List emergency plan that might be needed
Attached
and the sign/symptoms to watch for:
PREVENTIVE HEALTH SCREENINGS
date Performed
Record Value
Type Screening
Typ« Screening
Hearing
Hgb/Hct
Vision
Lead: QCapHlary OVertQUS
:
Dertt'al
T8 (mm of Induration)
Developmenial
Other
Scbliosis
Other:
Name of Health Care Provider (Print)
:Kft«iirt .Csr* ^reiMsr Stan*
; Special Equipment Needs
• List items riecessaiyfor daily activities
Date Pi?rformed
Signature/Date
CH-14
JAN 08
Dlsfribution; Orlginai-CniW Care Provider
Copy-PareniyGuardiari
Copy-Health Care Provider
Note If Abnormal
SMOKE RISE COOPERATIVE NURSERY SCHOOL
TUITION ASSIGNMENT FORM
Name:
Class:.
Phone Number:
E-mail:
Please check one:
Cooperative Tuition for 3-year old class: $2,100.00
Cooperative Tuition for 4-year old class: $2,700.00
Mandatory participation includes, but is not limited to, working on a
school committee, being placed on the cooking and substitution list,
and helping with one or more class parties. 'Fundraiser participation is
required for cooperative tuition.
**
Each family is responsible for a one-time donation of 2 Wet One
Antibacterial Wipe canisters, and one gallon of Apple Juice.**
Non-cooperative Tuition for 3-year old class: $2,700.00
Non-cooperative Tuition for 4-year old class: $3,300.00
No cooperative obligation is required for non-cooperative tuition. This means
that the family does not have to participate in a committee, two-week cooking
and substitution requirement, or class parties. Fundraiser participation is
required for non-cooperative tuition.
**
Each family is responsible for a one-time donation of 2 Wet One
Antibacterial Wipe canisters, and one gallon of Apple Juice.**
*****Payment obligation cannot be changed after October i******
tuition_forml/12
Description of Committee Positions
President:
The President is the executive officer of the corporation. She/he will preside at all meetings of
the Executive Board, the Board of Trustees and the General Membership. The President's
duties include appointing committees and chair people, planning the school calendar, aiding the
Treasurer in planning the budget and overseeing all major activities of the corporation.
1st Vice President:
The 1st VP shall assist the President and preside at meetings during the President's absence.
She/he is in charge of registration and enrollment and is assisted by the two Class Leaders.
2ND Vice President:
The 2nd VP shall arrange special in-school activities and organized field trips.
Secretary:
The Secretary completes the school handbooks and is responsible for their distribution to all
parents at the class coffees. She/he shall keep an updated list of all students and shall notify
members of any changes. The Secretary will send notices of all meetings and is responsible for
the school correspondences.
Treasurer:
This position is for a two-year term. The Treasurer shall be the custodian of the corporation's
funds and shall make payments in accordance with the budget. She/he shall keep full and
accurate accounts and present financial statements at the regular meetings of the corporation
and the Board. She/he is responsible for billing members quarterly for their tuition. The
Treasurer and the President sign all contracts and obligations authorized by the Executive Board
and approve in writing any transfer of moneys from checking accounts to savings accounts and
vice versa.
Class Leaders:
This is for your child's class. Each Class Leader shall host a Fall Coffee to introduce mothers/
fathers and organize class parties, projects, etc. Class Leaders are also responsible for starting
the class telephone chain, and help with the Teacher Appreciation Luncheon at the end of the
year. The Class Leader will assist the 1st VP in running the Open House. It is also the Class
Leaders responsibility to purchase and deliver snacks and paper products to the school. The
teachers will notify the Class Leaders as to what products to purchase and all receipts will be
submitted for reimbursement.
Equipment:
Generally meets four to five times per school year (additionally where needed) to clean and
maintain equipment in the classroom and playground. Approximate times to meet are August,
December/February, March/May. Chairperson is responsible for organizing dates and members
for cleaning and maintenance.
Special Functions:
Help prepare, set-up or clean-up refreshments and decorations for special events such as the
Father-Child Picnic, membership meetings, holiday programs, graduations, and Open House.
Each member will choose one way to help at all events.
Publicity:
Handles all advertising for the school including Open House, school registration, Kinnelon library
display, and tricky tray. Chairperson is responsible for assigning duties to committee members.
Chairperson should be comfortable working with computers to be able to update information on
the Nursery School website and Facebook account. Attends class functions and field trips.
Compiles and assembles a photographic DVD of school events. DVD is organized for each
class to be shown at the Spring Sing or Graduation. It is recommended that the chairperson
have knowledge of digital photography and processing.
Ways and Means:
This committee organizes and implements fund-raisers. Two chairpersons are needed to share
the responsibilities. Every member will work toward the success of our major fundraiser. Every
member will also work on sub-committees to coordinate one of our small fundraisers.
The Board of Trustees embodies the Executive Board, Class Leaders, and Committee Chairpersons.
The Executive Board embodies Director, President, 1st Vice President, 2nd Vice President, Secretary, and Treasurer.
Rev 1/11
Description_of_committee_positionssrev1/11
Cooperative
38 North Road
Kinnelon, New Jersey 07405
(973) 838-9088
Nursery School
Fund Raiser Information
Fund raisers help to support many aspects of our school such as field trips
and in-school visitors. Smoke Rise holds one major fond raiser and several
smaller fond raisers throughout the year. All families are required to sell two
tickets and to participate in the schools major fund raiser. Profit made
from this fond raiser supplements the budget and allows for those extra special
events that make Smoke Rise Nursery School special like the Fall Picnic and
the Mothers Day Brunch.
Thank you in advance for all your support and consideration regarding the
school's fond raiser. All questions should be directed to the current President
or to the current chairs of the Ways and Means Committee.