Enrollment Application - smokerisenurseryschool.org
Transcription
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.