St. Nicholas School

St. Nicholas School
Preschool Application
for Admission and Enrollment
2015-2016
9501 Balboa Blvd.
Northridge, California 91325
Phone: (818) 886-6751
  :
FAX: (818) 886-3933
“ON-GOING EXCELLENCE”
St. Nicholas School
Preschool Admissions Agreement 2015-2016
I have received and read the “Parents’ Handbook” and accept and agree to abide by these policies.
In addition, I understand:
_______There is a $275.00 non-refundable registration fee and a $75.00 non-refundable classroom supplies fee due
upon registration.
_______Tuition payments are made one month in advance throughout the school year. The first tuition payment is due
in June and all subsequent payments are due on a monthly basis throughout the school year, ending in May.
Students enrolling mid-year will have two tuition payments due at the time of registration.
_______Daycare, before and after school, is provided for an additional fee. I understand if I do not pick-up my child by
3:15 pm, my child will go to Daycare and I will be responsible for the fee.
_______A late payment of $20.00 is due with all payments made after the tenth of the month.
_______If a student is withdrawn during the school year, St. Nicholas School must be notified in writing at least 30 days
prior to withdrawal. The registration fee and classroom supplies fee is non-refundable.
_______Children who are ill (contagious) may not attend school. My child will be fever-free for 24 hours before
returning to school.
_______The school will administer medication as follows:
a. All prescription and non-prescription medication shall have an unaltered label and have the child’s
name and the date on it.
b. The school medication form, signed by the parent, must accompany any prescription or nonprescription medication to be administered during the school day.
_______It is my responsibility to sign my child in and out each day. I will furnish the school office in writing (on my
child’s emergency form) the name of each adult person I authorize to bring or pick up my child. Anyone not
named in writing will not be allowed to pick up my child in any circumstance, in accordance with regulations.
_______The Department of Social Services or licensing agency shall have the authority to interview children without
prior consent of the parents, and have the authority to observe the physical condition of the child, including
conditions which could indicate abuse, neglect or inappropriate placement, and to have a licensed medical
professional physically examine the child.
_______I will be given a start date for my child after all of the following forms have been completed and submitted to the
school office with the registration fee, the classroom supplies fee, and the tuition payment.
a. Enrollment Form
b. Tuition Agreement with Payment Plan and Schedule Options
c. Health and Emergency Information
d. Current Immunization Record
e. Physician’s Report
f. Birth Certificate/Passport
g. Notification of Parent’s Rights
h. Acknowledgement of Personal Rights
i. Acknowledgement of Receipt of Licensing Reports
Father’s Signature ______________________________________
Date____________________
Mother’s Signature ______________________________________ Date____________________
Legal Guardian’s Signature________________________________ Date____________________
Revised 5-1-2015
St. Nicholas School
Preschool Admissions Qualifications
St. Nicholas School is dedicated to the education of today’s youth by developing a strong academic foundation, and
building character along with artistic, physical, and social development bound with spiritual integrity. Our emphasis is
on cultivating a positive sense of self-confidence, independence, responsibility, and Christian love within a multicultural
faith community.
Applying to St. Nicholas School
To apply for admission to St. Nicholas School, all admissions documents must be completed and submitted, along with
the appropriate fees. It is best to make an appointment with the Registrar to submit your forms. New students may be
accepted for admission depending upon the number of openings available. Once classes are filled, all subsequent
applicants are placed on a waiting list for future openings, in the order they are received.
Admission Requirements for Preschool
Toddlers:
1. Must be 18 months to 30 months of age by the date admission is sought
2. Potty training is an essential part of the daily routine
Two-Year Olds:
1. Must be two years of age by September 1st of the academic year for which admission is sought
2. Must be toilet-trained (no diaper-like or training pants)
Three-Year Olds:
1. Must be three years of age by September 1st of the academic year for which admission is sought
2. Must be toilet-trained (no diaper-like or training pants)
Pre-Kindergarten:
1. Must be four years of age by September 1st of the academic year for which admission is sought
2. Must be toilet-trained (no diaper-like or training pants)
Start date will be determined when all admissions documents are completed and returned with payment including:
 a copy of the child’s birth certificate
 a copy of the immunization record
 a Physician’s Report completed by the child’s physician
Revised 5-1-2015
St. Nicholas School
Preschool Enrollment Form 2015-2016
Child’s Name_______________________________________________________
Last
First
Age as of September 1, 2015 ______________
Siblings at St. Nicholas School? Yes _____ No _____
Male _____
Female _____
Middle Initial
Birthdate______________________________
Name(s) _____________________________________________
Child’s Religion_________________________________________
Member of St. Nicholas Church?
Yes 
No 
Home Address__________________________________________________________________________________________
(Number and Street)
(City)
Home Phone_______________________________
Home e-mail address____________________________________
Mother’s Name____________________________________________
Living with child 
Separated/Divorced 
Work Phone__________________________________
(Zip Code)
Social Security # ________-______-________
Cell Phone_______________________________________
Email Address_________________________________________________________________________________________
Address (if different from above)___________________________________________________________________________
(Number and Street)
(City)
(Zip Code)
Employer_____________________________________________________________________________________________
Employer’s address_____________________________________________________________________________________
Father’s Name_____________________________________________
Living with child 
Separated/Divorced 
Work Phone____________________________________
Social Security # ________-______-_______
Cell Phone________________________________________
Email Address__________________________________________________________________________________________
Address (if different from above)____________________________________________________________________________
(Number and Street)
(City)
(Zip Code)
Employer______________________________________________________________________________________________
Employer’s address______________________________________________________________________________________
Guardian (If child not living with parents – Must furnish legal proof)
Social Security # ________-______-_______
Name__________________________________________
Relationship____________________________________
Work Phone_____________________________________
Cell Phone_____________________________________
Employer______________________________________________________________________________________________
Employer’s address______________________________________________________________________________________
(Over)
Revised 5-1-2015
Heard about St. Nicholas School through:
 Friend ____________________________
 Banner
 Brochure
 Greek Festival
 Website
 I am Alumni/Church Member
 Other___________________________________________________________________________________________
The following questions are for statistical purposes only. (Optional)
Child’s place of birth (city, state, country) ________________________________________
To which race/races does your child belong?
 Caucasian
 Native American/Alaska Native
 African American
 Native Hawaiian/ Pacific Islander
 Asian
 Hispanic
Of what national heritage do you consider your child a part? ___________________________________________________
I understand that withholding or misrepresenting information requested in this application may jeopardize admission or
enrollment at St. Nicholas School. My signature below indicates that all information contained in this application is correct,
complete, and honestly presented.
My signature also indicates that I give consent to allow my child’s picture to be used in any publication or on the website of
St. Nicholas School.
I UNDERSTAND AND AGREE THAT REGISTRATION FEES AND TUITION ARE NON-REFUNDABLE.
______________________________________________________
Signature of Mother or Guardian
_____________________
Date
______________________________________________________
Signature of Father or Guardian
_____________________
Date
NOTICE OF NON-DISCRIMINATION POLICY AS TO STUDENTS
St. Nicholas School, 9501 Balboa Blvd., Northridge, admits students of any race, color, national and ethnic origin to all the
rights, privileges, programs, and activities generally accorded or made available to students at St. Nicholas School.
St. Nicholas School does not discriminate on the basis of race, color, and/or national and ethnic origin in the administration
of its education policies, admissions policies, scholarship, athletic and other school-administered programs.
Revised 5-1-2015
St. Nicholas School
Enrollment Checklist
Please call the school office to set up an appointment with the Registrar to submit the following forms:
_____ Enrollment Form
_____ Preschool Admissions Agreement
_____ Acknowledgement of Personal Rights
_____ Notification of Parent’s Rights
_____ Acknowledgement of Receipt of Licensing Reports
_____ Tuition Agreement
_____ Schedule Options
_____ Daycare Agreement
_____ Tuition Payment Plan
_____ Health History
_____ Emergency Form
_____ Preschool Criteria
_____ Physician’s Report (completed by physician)
_____ Copy of Birth Certificate or Passport
_____ Copy of Child’s Immunization Record
_____ Registration Payment of $275
_____ Materials Fee $75
_____ First Month’s Tuition Payment
Revised 5-1-2015
St. Nicholas School
Preschool Criteria Sheet
NAME OF CHILD: __________________________
DATE OF BIRTH: ______________________
PLEASE CHECK WHAT APPLIES:
( )
Toilet trained
( )
Feeds self
( )
Needs help feeding self
( )
Eats almost all foods
( )
Eats very few foods
( )
Has temper tantrums
( )
Teases other children
( )
Overactive
( )
Highly excitable
( )
Timid and/or shy
( )
Plays well with others
( )
Is "picked on" by others
( )
Overly aggressive
(
(
(
(
(
(
(
(
(
(
(
(
(
)
)
)
)
)
)
)
)
)
)
)
)
)
Speaks understandably
Seldom speaks
Speaks in sentences
Does not speak English
Speech Impediment
Initiates own actions
Follows requests
Cares for own property
Is attentive
Has many interests
Few interests
Has many fears
Cries easily
MY CHILD NEEDS TO:
( )
Adjust to other children
( )
Become less active
( )
Become more active
( )
Become more cooperative
(
(
(
(
)
)
)
)
Manage anxiety better
Get interested in something
Acquire manual/motor skills
Become self-reliant
Please share any information that would help us understand your child’s development needs:
Revised 5-1-2015
St. Nicholas School
Tuition Rates and Agreement 2015 – 2016
Preschool
REGISTRATION FEE
MATERIALS FEE
FULL TIME
Monday-Friday 8:15 - 3:00
1 child
2 children
(Includes sibling discount)
3 children
(Includes sibling discount)
PART TIME 8:15 - 3:00
(No sibling discount available)
4 Full Days
3 Full Days
2 Full Days
HALF DAY 8:15 - 12:30
(No sibling discount available)
5 Half Days (Monday-Friday)
4 Half Days
3 Half Days
2 Half Days
$ 275 per child per year
$ 75 per child per year
STANDARD
MEMBERS*
Yearly
10 Months
Yearly
10 Months
$ 6,950
$ 695
$ 6,570
$ 657
$ 12,850
$ 1,285
$ 12,140
$ 1,214
$ 18,760
$ 1,876
$17,730
$ 1,773
STANDARD
MEMBERS*
Yearly
Monthly (10)
Yearly
Monthly (10)
$ 6,050
$ 5,000
$ 3,270
$ 605
$ 500
$ 327
$ 5,450
$ 4,500
$ 2,950
$ 545
$ 450
$ 295
STANDARD
MEMBERS*
Yearly
Monthly (10)
Yearly
Monthly (10)
$ 4,650
$ 4,380
$ 3,340
$ 2,780
$ 465
$ 438
$ 334
$ 278
$ 4,180
$ 3,950
$ 3,000
$ 2,500
$ 418
$ 395
$ 300
$ 250
Important Tuition Information







*
A Tuition Agreement must be signed for each school year by the parent(s)/legal guardian(s).
Registration Fees are discounted during early re-enrollment, and a late fee is assessed after June 1st.
All fees, advanced deposits, and tuition are non-refundable and non-excusable.
Once enrolled, payment of the full annual tuition amount is the responsibility of the party/parties signing the
Tuition Agreement.
Payment of the annual tuition is expected according to the terms of your designated monthly agreement.
Tuition credit for absences, family vacations, non-operational days, and closed holidays will not be given.
St. Nicholas School reserves the right to withhold student records, including but not limited to report cards, if the
status of an account is not current.
In order to qualify for and maintain the Members’ Tuition Discount, each year you must turn in a completed,
signed Pledge Card to the Church Office by December 31, for the upcoming year, and satisfy that pledge on a
timely basis. The discount cannot be more than 60% of your annual pledge. (For full-time students, this
represents a weekly Stewardship contribution of approximately $12 for 1 child.)
(Over)
Revised 5-1-2015
Payment Plans
One Payment: Due by August 15 for a 5% discount ($6,602 for Standard tuition and $6,242 for
Members*).
Two Payments: Due by August 15 and January 1 for a 5% discount ($3,301 for Standard tuition and
$3,121 for Members*).
Ten Payments: For returning students, the first payment is due by June 1. The remaining payments are due
September through May.
The Registration Fee which accompanies this application is non-refundable. Since our tuition schedule is on a
yearly basis, not monthly, all tuition payments are also non-refundable.
Accounts are delinquent if not paid by the tenth of the month. A late charge of $20 each month will be assessed on all
accounts not current by the tenth of each month. If an account is overdue by 30 days and no arrangements have been made
with the school office, the child will be suspended until the account is paid. There will be a $20 charge for all returned
checks.
I UNDERSTAND AND AGREE THAT REGISTRATION FEES AND TUITION ARE NON-REFUNDABLE.
_______________________________________________________________
Print Student’s Name
Entering grade for 2015 - 2016
_______________________________________________________________
Print Student’s Name
Entering grade for 2015 – 2016
_____________________________________________________________
Print Student’s Name
Entering grade for 2015 - 2016
___________________________________
Father's Signature
______________
Date
___________________________________
Mother's Signature
___________________________________
Guardian Signature
_______________________________________
Name of person responsible for payment
Revised 5-1-2015
_____________________________________________
Telephone or Cell Number
St. Nicholas School
Preschool Schedule Options
Student’s Name: __________________________________________
Birth Date: ____________
Parent/Guardian Signature: _______________________________
Date: _________________
I am registering my child for the option checked below. Any desired change must be approved by the Preschool
Director and the school office. To facilitate a smooth transition, we would appreciate at least two weeks’ notice, in
writing, prior to a change.

HALF TIME 8:15 - 12:30 5 Days: Monday – Friday




4 Days: M T W Th F
3 Days: M T W Th F
2 Days: M T W Th F
FULL TIME 8:15 - 3:00 5 Days: Monday – Friday



4 Days: M T W Th F
3 Days: M T W Th F
2 Days: M T W Th F
DAYCARE 3:00 - 6:00 5 Days: Monday – Friday



4 Days: M T W Th F
3 Days: M T W Th F
2 Days: M T W Th F
For Office Use
Approved by Preschool Director_________
Date__________
Start Date___________________________
Room_________
Approved by Financial Manager_________
Revised 5-1-2015
St. Nicholas School
Preschool Tuition Payment Plan 2015–2016
Student’s Name: _____________________________________
Birthdate: ______________________
Payment Plan (Check one):
One Payment: Due by August 15 for a 5% discount ($6,602 for Standard tuition and $6,242 for Members)
Two Payments: Due by August 15 and January 1 for a 5% discount ($3,301 for Standard tuition and $3,121 for
Members)
Ten Payments: For new students, the first payment is due upon enrollment. For returning students, the first
payment is due by June 1. The remaining payments are due September through May.
Automatic Payment (required for twelve payment plan)
If you have chosen the twelve-payment plan, or if you would like the convenience of having your tuition and daycare fees
paid on your debit or credit card each month, please fill out the information below
_______________________________________
Print Cardholder Name
___________________________________
Credit Card Number
Credit Card Type:
American Express
MasterCard
Discover
Visa
_______________ ________________ _____________
Expiration Date
Security Code
Billing Zip Code
I hereby authorize St. Nicholas School to apply tuition charges (and other approved items) to my credit card for the
2015-2016 school year per the payment plan chosen above. Please note: Credit cards that are denied by the
processing system are subject to late fees.
_______________________________________
Signature of Cardholder
Revised 5-1-2015
_____________________
Date
St. Nicholas School
Daycare Information and Fees 2015-2016
Daycare is available before and after school hours. It is provided either on a daily basis, as needed basis, or on a
scheduled monthly basis. Any student arriving before 7:40 a.m. will be charged for daycare. Monthly rates, which
include a 5% discount, are available for families who sign up in advance to use daycare every day and wish to pay
for it with monthly tuition. The discounted rates are listed below.
PRESCHOOL
K THROUGH 8TH GRADE
Before school
7:00 - 8:15 a.m.
MUST BE SIGNED IN BY ADULT
7:00 - 8:00 a.m.
MUST BE SIGNED IN BY ADULT
After School
3:00 - 6:00 p.m.
MUST BE SIGNED OUT BY ADULT
3:20 - 6:00 p.m.
MUST BE SIGNED OUT BY ADULT
DAYCARE RATE SCHEDULE
Daily Rates
Before School
After School
One child
Each additional child
$ 6 or $ 2 per 20 minutes
$ 5 or $ 2 per 20 minutes
$ 10
$ 8
Discount Monthly Rates
Morning Only
After School Only
Both
One child
Two children
Three children
$ 97
$ 178
$ 260
$ 162
$ 292
$ 422
$ 259
$ 470
$ 682
LATE FEES: If a student is dropped off before 7:00 a.m. or is NOT picked up and signed out by 6:00 p.m.,
a $12.00 fee per student will be charged for each half-hour, or any portion thereof.
------------------------------------------------------------------------------------------------------------------------------------------MONTHLY DAYCARE 2015 - 2016
Place a check mark in the boxes which apply.
My child/children
will be attending Daycare every day. Please sign them up for monthly rates to be billed with tuition.
My child/children
will not be attending Daycare every day.
PLEASE PRINT:
Before School
Only
CHILD'S NAME___________________________
GRADE_______
CHILD'S NAME___________________________
GRADE_______
CHILD'S NAME___________________________
GRADE_______
CHILD'S NAME___________________________
GRADE_______
After School
Only
Both
I have read and agree to abide by the rate schedule including the rule for the early drop off or late pickup fee.
PARENT SIGNATURE___________________________________
Revised 5-1-2015
DATE_______________________________
St. Nicholas Preschool 2015-2016 Schedule
 8:00 – 8:30
Children Arrive/Free Play
 8:30 – 9:00
Morning Stretch & Exercise (Outside)
 9:00 – 9:30
Circle Time
 9:30 – 10:00
Language Arts
 10:00 – 10:20
Snack
 10:20 – 10:50
Math
 10:50 – 11:15
Theme
 11:15 – 11:45
Recess
 11:45 – 11:50
Bathroom/Wash Hands
 11:50 -12:30
Lunch/Prep For Home & Nap
 12:45 – 2:30
Nap
 2:30 – 2:45
Wake Up & Snack
 2:45 – 3:00
Free Play/Prepare To Go Home 
Revised 5-1-2015