RHMP Application For Enrollment

Transcription

Student Name:
Richmond Hill Montessori Enrollment Packet
Welcome to Richmond Hill Montessori, we are glad you have chosen to allow us to be an integral part of your
child’s educational learning. RHM is an all-inclusive program providing diapers, wipes and diaper cream to our
non-potty trained children. We will strive daily to achieve and surpass the high expectations you have for your
childcare center.
At least 1 week before your child beginning his/her first day at RHM, we will need the following items:
Completed Application
Copy of Birth Certificate
Copy of Social Security Card
Registration Fee
*Supply Fee will be assessed on the first week
*Weekly Tuition is assessed the Friday
Parent Handbook Signature Page
Copy of Updated Form 3231 (Immunization Record)
Copy of Updated Form 3300 (Ear, Eye, Dental)
OR
3 Year-Old AAP Form Well Child – HE0493
Richmond Hill Montessori Preschool
Welcome to Richmond Hill Montessori, we are glad you have chosen to allow us to be an integral part of your
child’s educational learning. RHM is an all-inclusive program providing diapers, wipes and diaper cream to our
non-potty trained children. We will strive daily to achieve and surpass the high expectations you have for your
childcare center.
On your child’s first day, please remember to bring in the following:
2 Complete Change of Clothing: Shirt, Pants, Socks
Underwear (if applicable)
Happi Nappi (RHM provided)
Water bottle
Please label with permanent marker all of your child’s belongings. Water bottles should be taken home daily to
wash. Happi Nappi should go home with your child on Fridays for laundering. We look forward to being a
positive adjunct to your child’s growing experience. Thank you for choosing Richmond Hill Montessori.
Accompanied by/Informant
Preferred Language
Drug Allergies
Date/Time
Name
Current Medications
Weight (%)
Height (%)
BMI (%)
ID Number
Blood Pressure
Temperature
Birth Date
Age
M | F
History
Physical Examination
□Previsit Questionnaire Reviewed □Child has special health care
needs
□Child has a dental home
Concerns and questions: □None □Addressed (see other side)
Follow-up on previous concerns: □None
Interval history
□Addressed (see other side)
□None □Addressed (see other side)
□NL
Bright Futures Priority
Additional Systems
□ Eyes (red reflex,
cover/uncover test)
□Teeth (canines, white
spots, staining)
□Neurologic (language,
speech, social interaction)
□General Appearance
□Head
□Ears
□Nose
□Mouth and Throat
□Neck
□Lungs
□Heart
□Abdomen
□Genitalia
□Extremities
□Back
□Skin
Abnormal findings and comments
Assessment
□Well Child
Social/Family History
See initial History Questionnaire
□No interval change
Family situation
Parents working outside home
Child care:
□Yes
□Yes
Preschool:
Changes since last visit:
□No
□No
□Mother □Father
Type:
Type:
Review of Systems
See Initial History Questionnaire and Problem List.
□No interval change
Changes since last visit:
Nutrition:
Elimination:
□NL
Toilet training:
□Yes □In process
Sleep:
□NL
Behavior/Temperament:
□NL
Physical activity
Play time (60 min/d)
□Yes
□No
Screen time (<2 h/d)
□Yes
□No
Parent-child interaction
Communication: □NL
Choices: □NL
Cooperation: □NL
Appropriate responses to behavior: □NL
Anticipatory Guidance
□Discussed and/or handout given
Family support
 Show affection
 Manage anger
 Reinforce
appropriate
behavior
 Reinforce limits
 Find time for
yourself
Encourage literacy
activities
 Read, sing, play
 Talk about
pictures in books
 Encourage child
to talk
Immunization (See Vaccine Administration Record)
Laboratory/Screening results: □ Vision
□ Referral to
Follow-up/Next visit
Social-Emotional
 Self-care skills
 Imaginative play
□See other side







Physical Development
Builds tower (6-8 blocks)
Stands on foot
Throws ball overhand
Walks upstairs alternating feet
Copies circle
Draws person (2 body parts)
Toilet trained during day
Safety
 Car safety seat
 Supervise play near
cars and street
 Safety near windows
 Guns
Plan
□Development (if not reviewed in the Pre-visit Questionnaire)
Communications
 2-3 sentences
 Usually
understandable
 Names a friend
 Names objects
 Knows if boy or
girl
Playing with Peers
 Encourage
appropriate play
 Encourage
fantasy play
 Encourage play
with peers
Promoting
physical activity
 Family exercise
activities
 Limit screen time
(max 2 hr/day)
 No TV in
bedroom
Print Name
Resident
Signature
Provider
WELL CHILD/3 years
For official use only
Admin initial:
TUITION AGREEMENT FORM
At the time of your child’s enrollment and every year thereafter, you will be asked to sign a tuition agreement.
An annual registration/supply fee of $125 and $75 respectfully is due upon your child’s enrollment into the
center and on August 1st of each year thereafter.
Weekly payments are due on Friday prior to the service week. A $25 late fee will be assessed to the account
on Monday. RHM will gladly continue to care for your child on Tuesday provided tuition and late fees have
been paid. RHM reserves the right to deny child care on delinquent accounts.
There will be a service charge of $35.00 for all returned ACH payments and a late fee of $25. The now late
payment must be made by money order, cashier check, or cash.
All children must be picked-up no later than 6:15 p.m. Anyone arriving after 6:15 will be charged $20.00 plus
an additional $1.00 every minute. This fee must be paid before the child may return to school.
All tuition amounts are based on the total yearly cost of the program. The weekly and monthly fees are a
breakdown of this yearly cost to facilitate parent payments.
There are three tuition payment methods made available to parents for flexibility. Please
select one of the following:
□ Weekly
□ Bi-Weekly
$
$
due on Friday prior to the service week
due on Friday every other week
*Please see front desk for Bi-Weekly schedule section
□ Monthly
$
due on the 1st of each month
Child’s Name
Date
Parent/Guardian Print Name
Parent/Guardian Signature
Who can we thank for referring you to Richmond Hill Montessori Preschool?
______________________________________
Admin initial:
Child Enrollment Form
Please fill out the Following Application Completely. Include Street Name, Number, City, State, and Zip Code.
Entrance Date:
Withdrawal Date:
Child’s Name:
Sex:
Home Address :
Age:
Birth Date: ____/____/____
City:
State:
Zip:
Father/Guardian Information (write N/A for all areas that are not applicable to your circumstances)
Name:
Email:
Home Address :
City:
State:
Zip:
If different from child’s
Cell Phone:
Cellular Provider:
Employer:
Home Phone:
Business Phone:
Address:
City:
State:
Zip:
Mother/Guardian Information (write N/A for all areas that are not applicable to your circumstances)
Name:
Email:
Home Address :
City:
State:
Zip:
If different from child’s
Cell Phone:
Cellular Provider:
Employer:
Home Phone:
Business Phone:
Address:
City:
State:
Parent/Guardian Authorization

Child’s Living Arrangements:
□ Both
□ Mother
□ Father
□ Other:

Child’s Legal Guardian(s):
□ Both
□ Mother
□ Father
□ Other:

Authorized Pick up:
□ Both
□ Mother
□ Father
□ Other:

Emergency Contact:
□ Both
□ Mother
□ Father
□ Other:
Zip:
Admin initial:
Additional Authorization List
I also recognize the following individuals as emergency contacts/authorized pick-ups:
*Please include home addresses for each individual listed. *Please note any future changes must be done in person or in writing
Name #1:
Relationship:
Home Address :
City:
Phone #:
□ Authorized Pick-up
Name #2:
State:
Zip:
□ Emergency Contact
Relationship:
Home Address :
City:
Phone #:
Name #3:
State:
Zip:
Relationship:
Home Address :
City:
State:
Phone #:
Zip:
Child Information
Public or private school child attends, if any:
Child’s Physician/Clinic:
Phone #:
My child has the following special need(s):
The following special accommodation(s) may be required to most effectively meet my child’s needs while at
this center: i
My child is currently on medication(s) prescribed for long-term continuous use and/or has the following preexisting illness, allergies, or health concerns:i
Before coming to RHMP my child was cared for:
□ At another child care center. Center’s Name:
□ At home by a parent or grandparent
□ At an in-home babysitter □ Other:
Print Parent/Guardian Name
Signature of Parent/Guardian
State:
Date
Parental Agreements with Richmond Hill Montessori Preschool
Richmond Hill Montessori Preschool agrees to provide care for my child,
on
Monday – Friday
from
a.m. to
p.m. (Estimated typical drop off and pick up time)
My child will participate in the following meal plan (circle applicable meals and snacks):
Breakfast (7:30-8)
Morning Snack
Lunch (11am)
Afternoon snack (2pm)
Before any medication is dispensed to my child, I will provide a written authorization, which includes: name of
child, date, name of medication, prescription number (if applicable), dosage(s), date and time of day medication
is to be given. Medication will be in the original container with my child’s name marked on it.
My child will not be allowed to enter or leave the facility without being escorted by the parent(s), or person
authorized by the parent(s), or facility personnel. Only extended care children will be signed in at the front desk
by guardian and escorted to proper room. All other Lottery Pre-K are required to use car rider line.
I acknowledge it is my responsibility to keep my child’s records current to reflect any significant changes as
they occur, e.g., telephone numbers, work location, emergency contacts, child’s physician, child’s health status,
infant feeding plans and immunization records, etc.
The facility agrees to keep me reasonably informed of any incidents, including illnesses, injuries, adverse
reactions to medications, etc., which include my child. The facility also agrees to advise me of my child’s
progress and issues related to my child’s care and special needs.
Richmond Hill Montessori Preschool agrees to obtain written authorization from me before my child
participates in routine transportation, field trips, special activities away from the facility, and water related
activities occurring in water that is more than two feet deep.
I am encouraged to participate in special activities at the center.
I authorize Richmond Hill Montessori Preschool to obtain emergency medical care for my child when I am not
available.
I have received a copy of the parent handbook and center policies and procedures, and I agree to abide by the
policies and procedures for Richmond Hill Montessori Preschool.
Parent/Guardian Name
Date
Parent/Guardian Email Address: ____________________________________ (Should be checked regularly)
EMERGENCY MEDICAL AUTHORIZATION
Should
,
(Child’s Name)
suffer any injury
(Date of Birth)
or illness while in the care of
and the facility are unable to
contact me/us immediately, it shall be authorized to secure such medical attention and care for the child as
necessary. I/we agree the facility informed of changes in telephone numbers, etc. where I /we can be reached.
The facility agrees to keep me informed of any incidents requiring professional medical attention involving my
child.
Child’s primary source of health care is:
Physician/Clinic Name
Telephone Number
Known medical conditions (i.e.) diabetic, asthmatic, drug allergies:
Date
VEHICLE EMERGENCY MEDICAL INFORMATION
Child’s Name:
Date of Birth:
Home Address:
City:
State:
Father’s Name:
Mobile:
Work Phone:
Mother’s Name:
Mobile:
Work Phone:
Zip:
Person to notify in an emergency if parents cannot be reached:
Name:
Relationship:
Phone:
Other emergency contacts (if applicable):
Child’s Doctor:
Phone:
Medical Facility:
Phone:
Other emergency information:
Child’s allergies:
Current prescribed medications:
Child’s special needs/conditions:
In the event of an emergency involving my child, and
cannot
get in touch with me, I hereby authorize any needed emergency medical care. I further agree to be fully
responsible for all medical expenses incurred during the treatment of my child.
Date
Authorization to Dispense External Preparations
590-1-1-.20(1)
Parental Authorization. Except for first air, personnel shall not dispense prescription or non-prescription
medications to a child without specific written authorization from the child’s physician or parent. Such
authorization will include, when applicable, date; full name of the child; name of the medication; prescription
number, if any; dosage; the dates to be given; the time of day to be dispensed; and signature of the parent.
I give
permission to apply one or more of the following
topical ointments/preparations to my child in accordance with the directions on the label of the container.

Baby wipes

Band-Aids

Neosporin or similar ointment

Bactine or similar first aid spray

Sunscreen (Rocky Mountain Peak)

Insect Repellant (Parent Provided)

Non-Prescription ointment (such as A & D, Desitin, Vaseline)

Baby powder

Other (please specify)
Date
Admin initial:
Food Allergy Action Plan
Student’s Name:
D.O.B:
Teacher:
ALLERGY TO:
Asthmatic
Yes*
No
*Higher risk for severe reaction
STEP 1: TREATMENT
Give Checked Medication**:
**(To be determined by physician authorizing treatment)
Symptoms:
If a food allergen has been ingested, but no symptoms:
 Epinephrine
 Antihistamine
o Mouth:
o Skin:
Itching, tingling, or swelling of lips, tongue, mouth
Hives, itchy rash, swelling of the face or extremities
 Epinephrine
 Epinephrine
 Antihistamine
 Antihistamine
o Gut:
o Throat†:
Nausea, abdominal cramps, vomiting, diarrhea
 Epinephrine
 Antihistamine
Tightening of throat, hoarseness, hacking cough
 Epinephrine
 Antihistamine
o Lung†:
Shortness of breath, repetitive coughing, wheezing
 Epinephrine
 Antihistamine
o Heart†:
Thready pulse, low blood pressure, fainting, pale, blueness
 Epinephrine
 Antihistamine
 Epinephrine
 Antihistamine
 Epinephrine
 Antihistamine
o Other†:
________________________________________________
If reaction is progressing (several of the above areas affected), give
The severity of symptoms can quickly change. †Potentially life-threatening.
DOSAGE
Epinephrine: inject intramuscularly (circle one) EpiPen® EpiPen® Jr. Twinject™ 0.3 mg Twinject™ 0.15 mg
Antihistamine: give____________________________________________________________________________________
medication/dose/route
Other: give___________________________________________________________________________________________
medication/dose/route
IMPORTANT: Asthma inhalers and/or antihistamines cannot be depended on to replace epinephrine in anaphylaxis.

STEP 2: EMERGENCY CALLS

1. Call 911 (or Rescue Squad: ________________________ ) . State that an allergic reaction has been treated, and additional
epinephrine
may be needed.
2. Dr. ____________________________________ at ____________________________________
3. Emergency contacts:
Name/Relationship
Phone Number(s)
a. ____________________________________________
1.)________________________
2.) ______________________
b. ____________________________________________
1.)________________________
2.) ______________________
c. ____________________________________________
1.)________________________
2.) ______________________
EVEN IF PARENT/GUARDIAN CANNOT BE REACHED, DO NOT HESITATE TO MEDICATE OR TAKE CHILD TO MEDICAL FACILITY!
Parent/Guardian Signature:
Date:
Doctor’s Signature:
Date:
(Required)
TRAINED STAFF MEMBERS
1. ____________________________________________________
Room ________
2. ____________________________________________________
Room ________
3. ____________________________________________________
Room ________
EpiPen® and EpiPen® Jr. Directions
Twinject™ 0.3 mg and Twinject™ 0.15 mg
Directions
Pull off gray activation cap.
Hold black tip near outer thigh (always
apply to thigh).
Pull off green end cap, then red end cap.
Put gray cap against outer
thigh, press down firmly
until needle penetrates. Hold
for 10 seconds, then
remove.
Swing and jab firmly into outer thigh
until Auto-Injector mechanism
functions. Hold in place and count
to 10. Remove the EpiPen® unit and
massage the injection area for 10
seconds.
SECOND DOSE ADMINISTRATION:
If symptoms don’t improve after
10 minutes, administer second
dose:
Unscrew gray cap and pull
syringe from barrel by holding
blue collar at needle base.
Slide yellow or orange collar
off plunger.
Put needle into thigh through
skin, push plunger down all
the way, and remove.
Once EpiPen® or Twinject™ is used, call the Rescue Squad. Take the used unit with you to
the Emergency Room. Plan to stay for observation at the Emergency Room for at least 4
hours.
For children with multiple food allergies, consider providing separate Action Plans for
different foods.
**Medication checklist adapted from the Authorization of Emergency Treatment form developed by
the Mount Sinai School of Medicine. Used with permission.
Admin initial:
10200 Ford Ave, Suite 107, Richmond Hill, GA 31324 > 912-756-4554
PARENT RESPONSIBILITIES AGREEMENT







I/we agree to communicate with provider regarding the needs of the child.
I/we agree to immediately inform the childcare center of any changes in emergency/contact information.
I/we agree to keep child’s immunizations and physical records current as required by Department of
Children & Families.
I/we agree to keep a sick child home, including a child that is too ill to participate in the daily indoor and
outdoor activities, or pick up a sick child in a timely manner (less than 45 minutes) in accordance with the
policy.
I/we agree to check the daily communication folder and comment/input or initial as necessary.
I/we agree to meet with child’s teacher after 6 weeks and near the end of the school year to discuss my
child’s portfolio, progress notes, development and plan goals together for the current and following year.
I/we agree to volunteer our time, talent and or services to my child’s classroom, curriculum or school on
one or more occasions each school year.
CENTER RESPONSIBILITIES AGREEMENT






I/we agree to communicate with parent regarding the needs of the child.
I/we agree to immediately inform the parent through the Parent Handbook, monthly newsletters and
posting information on the Front Bulletin board.
I/we agree to keep a current copy of child’s immunizations and physical records provided by the parent as
required by Department of Children & Families.
I/we agree to inform parent of a sick child and isolate a sick child in a timely manner in accordance with
policy.
I/we agree to provide a daily communication folder and comment/input as necessary.
I/we agree to meet with child’s parent after 6 weeks and near the end of the school year to discuss child’s
portfolio, progress notes, and development and plan goals together for the current and following year.
PARENT RELEASE FOR FIELD TRIPS
I / We consent to _____________________________(child name) going on and/or participating in supervised
field trips and activities while enrolled at Richmond Hill Montessori Preschool and agree to release and
discharge the center’s officers, agents and employees, exercising reasonable care within their employment,
from liability growing out of personal injuries and property damage resulting or occurring during the
aforementioned field trips and activities, or in transit to and from the activity(ies). Payment of the activity fee, if
applicable, is indicative of my knowledge of the scheduled field trip or activity. On occasion, my child may
participate in an unscheduled field trip or activity.
PARENT AUDIO / VIDEO / PHOTO RELEASE
I / We consent to _____________________________ (child name) being tape recorded, video recorded, or
photographed for educational or publicity purposes while participating in the regular activities of this program.
Date
Admin initial:
SUNSCREEN AND INSECT REPELLANT PERMISSION SLIP
 RHM will apply Rocky Mountain Peak Sunscreen for all of our students in the
afternoon. Rocky Mountain Peak is SPF 50, fragrance free, oxybenzone free,
water resistant for 80 minutes, hypoallergenic, and greaseless.
 Parent will apply the sunscreen of choice on their student in the morning prior to
dropping off.
 Parent will provide insect repellant of choice in the original container with valid
expiration date, and labeled with student’s name for teacher and classroom use
(must be non-aerosol cans).
I give
provided sunscreen
Rocky Mountain Peak
insect repellant
permission to apply the program
and the following non-aerosol can
for my child
in the afternoon prior to going outside.
*I understand that it is my responsibility to apply sunscreen to my child in the morning prior to drop off and
the teacher’s will reapply in the afternoon prior to going outside when applicable.
SPECIAL INSTRUCTIONS:
Insect Repellent:
Date
Program Survey Form
The survey date is
STUDENT INFORMATION
Student’s Last Name
First Name
Address
M.I.
Date of Birth
Grade
City
If the above property is a federal property, enter the name
of the property.
School Name
State
Zip Code
Name of federal property
PARENT/GUARDIAN EMPLOYMENT INFORMATION: CIVILIAN
Enter information in this section regarding the parent/guardian if 1) neither parent/guardian with whom the student resided was on active duty in the
Uniformed Services of the United States and 2) either parent/guardian with whom the student resided was employed on federal property, or 3) either
the parent/guardian reported to work on federal property on the survey date. Enter the parent/guardian’s name as it appears on the employer’s payroll
record.
Parent/Guardian’s Last Name
First Name and M.I.
Address of Parent/Guardian’s Employer
Name of Parent/Guardian’s Employer
City
State
Zip Code
City
State
Zip Code
Address of federal property
PARENT/GUARDIAN EMPLOYMENT INFORMATION: UNIFORMED SERVICES
Enter information in this section regarding the parent/guardian if either person was on active duty in the Uniformed Services of the United States on
the survey date.
First Name and M.I.
Branch of Service
Rank
PARENT/GUARDIAN EMPLOYMENT INFORMATION: FOREIGN MILITARY
Enter information in this section regarding the parent/guardian if either person was both an accredited foreign government official and a foreign
military officer on the survey date.
First Name and M.I.
Branch of Service
Rank
Name of Foreign Government
PARENT/GUARDIAN EMPLOYMENT INFORMATION: FARMING, GRAZING, LUMBERING AND MINING
Enter information in this section if either the parent or guardian spent more than 50 percent of his or her working time on federal property (whether as
an employee or self-employed) engaged in farming, grazing, lumbering or mining.
First Name and M.I.
Name of Parent's/Guardian’s Employer
Address of Parent/Guardian’s Employer
City
Address of federal property
Permit Number
Township
Range
State
Section
Signature of Parent/Guardian________________________________Date_________________
Zip Code
Admin initial:
Parent Handbook Agreement
The RHM handbook can be found on the school’s website at:
www.richmondhillmontessoripreschool.com
***Please see front desk for the site password
Classroom lesson plans, monthly lunch menu, and the lottery pre-k school calendar can also be found on the
website.
I have read the RHM Parent Handbook and understand its content.
Child’s Name
Date
Admin initial:
Biting Policy
Biting is a natural part of a child’s development. Children bite for a wide variety of reasons such as teething,
lack of verbal skills, over stimulated, hungry, tired, aggression, attention-getting device, etc. Biting is an issue
that often surfaces when infants, toddlers and preschoolers are in a child care setting.
Biting, however, is not an acceptable behavior at RHM.
The staff will carefully, thoughtfully, and consistently handle the biting situation by:
 Stopping the action quickly by saying “No” or “Stop”
 Assessing the situation quickly to determine the cause of biting (child’s frustration, hunger, teething,
fatigue, separation anxiety, etc.)
 Attending to the child that has been bit with lots of TLC and attention.
 Talking to the biter in the following manner:
 “Biting hurts; teeth are not for biting our friends”. Teeth are for eating food”.
 “It is okay to be upset, but it is not okay to bite our friends”. Use your words for what bothers you
and the teacher will help you”.
 Redirecting the biter to another activity or area
 Finishing the interaction on a positive note by reassuring the biter that he or she is still important to you
and the rest of the staff.
If a bite breaks the skin and or draws blood the child will be sent home for the day.
The childcare staff will notify the parents of the biter and the parents of the child that was bit with a call and in
writing stressing the severity or mildness of the incidents.
Parents will be asked to work cooperatively with the childcare center staff to rectify the biting situation.
If the child bites a second time, staff will contact the parents to notify them of the biting. Staff will continue
working with the student and family to stop the biting behavior. The third time the child bites the child’s parents
will be notified to pick up their child for the day. If the child bites thereafter they will be sent home for 3 days.
During this time the staff will assess the room and modify any necessary changes to better help the child to stop
the biting. If nothing works and the child continues to bites and injure other children, it will be necessary for the
parent to make other child care arrangements. At which time the child will be asked to withdraw from the
program, the parents will be given one (1) week to find other suitable child care arrangements.
It is the responsibility of the childcare center staff to ensure the safety of all children under our care.
Date
Child’s Name:
Birth Date:
Sex:
Place of Birth:
Name of Mother or guardian:
Age:
Occupation:
Work Phone:
Name of Father or guardian:
Age:
Occupation:
Work Phone:
Marital Status of Parents:
Custody/Visiting Arrangements:
If child is adopted, list age at adoption:
Is child aware of adoption:
List siblings and their ages:
Are there other members of the household? If so, list name, age and relationship
__________________________________________________________________________________________
________________________________________________________________________
Is your child toilet trained:
Describe any assistance needed and words used:
If your child naps, when does he/she nap?
What time does your child go to bed at night?
Wake up?
Does your child have any special fears?
Does your child have any problems with vision or hearing? ____________ If so, please explain:
List and explain any health problems we should be aware of:
List illnesses you child has had:
Does your child have frequent colds? __________________________ Ear Aches?
Sore throat?
Stomach aches?
Fevers?
Has your child had any serious accidents or operations? _______________ If so please explain
Does your child have any allergies? __________ If so please describe
Does your child take any regular medication? ___________If so, please describe
Are there any special medical, physical or emotional needs that the school or staff should be aware of?
__________________________________________________________________________________________
__________________________________________________________________________________________
Does your child play well alone? _____________________ In groups?
Are there any neighborhood playmates? ___________________ If so, with what age children does your child
usually play?
Does your child accept correction easily? ___________________ What is the method of behavior control used
in your home?
Please circle items below that describe your child:
Happy
Aggressive
Friendly
Moody
Clumsy
Dependant
Stubborn
Impulsive
Fearful
Quiet
Good-Natured
Even-tempered
Attentive
Sympathetic
Shy
Sleepy
Other
Has your child learned to (please check):
Say nursery rhymes?
Sing songs?
Say his or her name?
State his or her age and sex?
Count?
How far?
Listen to stories?
Dress independently?
Recognize and name common objects?
Follow simple directions?
Ride a tricycle?
Throw and catch a ball?
Name basic colors?
Hop on one foot?
Balance on one foot?
Write name?
Draw a person?
accomplishments):
Has your child had group play experience?
Other? (Please note additional significant
Has your child been cared for by someone besides the family? __________ Whom
Has your child gone to pre-school or daycare before? _____________ Please describe previous experiences
What do you hope will be included in your child’s pre-school program?
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
What language does your family speak at home?
______
Is there any other language other than English that is spoken in the home?
If yes, what language
______
*This information will assist teachers and staff in developing any accommodations that may be relevant to
curriculum understanding to assist with individual learning success
Family nationality
Religious preference
Are there any holidays that you do not wish your child to celebrate?
®
Automated Payment Processing
Safe – Convenient – Easy
We are excited to offer the safety, convenience and ease of Tuition Express ® – an automatic payment processing system that allows
on-time tuition and fee payments to be made from your bank account.
Child’s Name
ELECTRONIC FUNDS TRANSFER AUTHORIZATION FOR BANK
ACCOUNT AUTHORIZATION
I (we) hereby authorize
(business name) to initiate debit entries to my
(our) Checking or Savings Account indicated below. To properly affect the cancellation of this agreement, I (we) are required to give
10 days written notice.
Credit Union Members: Please contact your Credit Union to verify account and routing numbers for automatic payments.
_______________________________________________________________________________________________________
Your Name
Phone #
_______________________________________________________________________________________________________
Address
City
State
Zip
_______________________________________________________________________________________________________
Bank or Credit Union Name
_______________________________________________________________________________________________________
Bank or Credit Union Address
City
State
Zip
____________________________________________________________________________________
Routing Transit Number (see sample below)
Checking Savings
Account Number (see sample below)
_______________________________________________________________________________________________________
Signature
Date
Check if you wish to make online payments
A service of
For Official Use Only
Date Received
________________________
Employee Signature
________________________
Copyright Procare Software 04-05-2013

RHMP Application For Enrollment

Transcription

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