Crescent Aca demy Early Leamers Program Barly Childhood Development program for 3 %year old children (hy September) ein =chatacter | Mrs. Green, Progra Director MRS. Ford, Grollraent Director 24BADZASEL Program Eligibility Requirements: Enroll Now...requirements Tuition Information This not a drop in Ezrly Childhood Ec © Complete and return the Application program must adhere tothe payment with supporting documents, + Child must be 3% on or before © Tuition: $100 weekly fee September!" yrs olf no later than | © Non refundable $25 registration fee 3/31}, + DHS Payments Accepted ‘* Must be completely potty trained. ‘© Original Birth Certificate Health Appraisal and immunization Acceptance is subject to spaceREGISTRATION CHECK LIST Early Learners Program Application Emergent curriculum is a philosophy of teaching and way of planning curriculum that focuses on being responsive to chiliren's interests to create meaningful learning experiences. Child must be 3 % on or before September 1° Verification documentation is required to process the application. STUDENT'S NAME Inquiry Date L Early Learners Program Azpliation Signature Page 2 Parent/Guardian Contact information 3, ____ Child's Heath and Developmental Data 4 Ccurrent Guardian's Driver's Licanse Birth Certificate (original must be presented!) 6. Immunizations Health Appraisal Form (physician has completedo Date of Acceptance: ts© Early Learners Program Application (5 Days Monday —Friday—9:00 a.m-3:00 p.m.) Latch Key Available for an additional fee [ALLINFORMATION ON THIS APPLICATION WILE KEPT CONFIDENTIAL Child’s Name Age __ Address: | Genoer © Male Female ETHNIC BACKGROUND African American (Black) Caucasian (white) Hispanic ‘American indian Asian/Pacific lander Multi-racal—explain Birth Date pee BL cz iy: .f (ait Disaoury Status © NolEP/lFSP © TEPYIFSP in place © Suspected Disability, no IEP/ IFSP : ‘WHO DOES THe STUDENT LIVE WITH? Both Parents_ Father/Stepmather Mother/Stepfether__ Guardian Relative Foster Home _ Court Placed Primary Language spoken in the home 2. What language do you most often use to speak to your child? 3. Hasyour child ever attended pre-school? Pavent/ Guaroia SIGNATURE English Other English Other: — No Yes Date‘Name: ‘Nar eh sinh bate re ‘What's the relationship with the child? ~ Whats the relationship with the child? How does the child refer to this adult? How does the child refer to this adult? last Grade Completed: last Grade Completed: Day Phone # - Day Phone f E-mail Address E-mail Address — | Employer: # Employer L Work Phone: ‘Work Phone: Who else does the child live with? Please check Name:__ Relationship to Child V__ nents Name: Relationship to Child v Aten cescert Name: Relationship to Child Hey amentscrsct Name:____ Relationship to chit is Y_saarisorocae Name Relationship to Child Ven crescent Who has legal custody of the child? (Verification Documentation Required)* Relationship: Name( + if guardian or foster parent (other than biological parent), please fillin the space below, as well as ony information that is known about the mother and/or father in the above boxes. Foster Parent / Legal Guardian (other than parent) Name: Address: __ Phone Number: Parent / Guardian Signature: Date: certify tata the Paret/egal uacan al iformation provide above ftv and accra and that my chi and reside at these adres tet frat mye tot esis Rete Apion and esc agus nd shang fm an py yar MUS ocurmentaton and proof oresence an Income Veriton Form with lated incre dacements¥an Once we : seen able to officially enroll children until mic-July and we expect that to tnrlinent in previo ears. ase now i previous eos we hve not. CHILD'S HEALTH AND DEVELOPMENT DATA Survey ‘STUDENT NAME, HEALTH INFORMATION: 1. Has your child blems in the infant years? __Yes _No 1 special growth and developmental iF yes, please explain /ourchilé have any Physical Disabltes/ Physical Handicaps? _ 3. Does your chil show good eoordination? ee 4. Long term/chronietlinas of child? fons tubes in ears, asthma, ete) IAL INFORMATION: sauder ree any fhe long spec ss er preva? | | __ ing __ceapaton repr seca tation __couseingPocholgst—_ Pn meapy Spee sot ore omnes esses _ : | 2, Does your child wear any of the following? eye Glasses Hearing Device __Physical Brace ther, please Ist, 3. Has your child ever been referred for testing? _ Yes _No What typeof testing? Referred by whom? a:‘OTHER FANIILY MEMBER(s) HEALTIL INFORMATION: Have any brothers, sisters or parents ever had any school services such as: PPL, Speech or Physical Therapy, Teacher Consultant, ete. Yes No 4. Is there anything you can tellus about your child that would be helpful? For exemple: language deficiency, behavior concerns, personality tals, et. 2._ Are there any family circumstances that would be helpful to know? SOCIAL RELATIONS: By nature is your child rien? Aseressve sty____or withdrawn, Do you fel your hid austs easly 92 core stuatlon? __ How does your child show his/her feelings? Is your hil frightened of any of he following? Animals, Datk__toudNolses_Storms_ Does child speakin words? __Sentences_other language ss Isyourehié oat waned? Can the chi inate hier batroom wishes? Wrd/phrase used ta nate “Pet” Fave frequent tle ecm Does your what evel of astance does your ci ead when using the restroom? a SELF HELP SIO Isyourctild able to fly dress his/her self? —_EwerGency INFORMATION DOCUMENT STUDENT INFORMATION: Student Name: EMERGENCY CONTACT INFORMATION: Name and phone number of an adult we can contact i the parent/guardian cannot be reached. Name Relationship to Student Day/ Phone Number Alternate Nurnb Name Relationship to Student Day/ Phone Number _Alternate Number Name Relationship to Student Day/Phone Number _Altemate Number Legally, do not release my child to: Please Note: The Academy will not comply with your request until receipt of Personal Protection Order and/or Custody Papers. Completion ofthis portion wll authorize the school staf to contact your childs physician and to act on his/her advice for treatment in the event that your childs Injured or il ata school sponsored activity. ttalso authorizes the school staff to contact another physilan for direction In the event your physician is not available. Inall cases, ‘an effort will be made to contact the parent, guardian or designated emergency contact person frst. Note: Be sure to consider carefully who your emergency contact person willbe (above) and that they understand it wil be his/her responsiblity to authorize treatment if you cannot be reached. Note: f considered necessary by school administration, 811 emergency personnel willbe contacted Immediately. In the event of a medical emergency, and lor my designated contact person cannat be reached, | authorize _to receive medical treatment from our physician or alternate physician frame below)Name of Physician: Phone: Address tS itenate Physician: pe Hospital Preferred ‘ Health Insurance Provider: eS Number: Ambulance Service Pref Note: | authorize ambulance service if required and understand that lam responsible for payment ofthis bl y N [ Please nate any spect health conditions, allergies or medication reactions for your son/daughter. Cl medications: te | | Gastnms Chee stings Choinbetes AleroPhotograph and Publicity Release Form _, give Crescent Academy and its fiscal agent, if any, permission to use ‘my child’s name, likeness, image, voice, and/or appearance as such may be embodied in any pic photos, video recordings, auciotapes, digital images, and the like, taken or made on behalf of Crescent Academy. lagree that Crescent Academy may have complete own ip of such pictures, etc, including the entire ‘copyright, and may use them for any purpose consistent with Academy's missions. Th buta publications, advertisements, and any promotional or other materials in any medium now known or ‘ot limited to, ilustrations, bulletins, hibitions, videotapes, reprints, reproductions, later developed, including the Internet. 1 acknowledge that | will nt receive any compensation, etc. for use of such pictures, etc, and hereby release Crescent Academy and its agents and assigns from any and all claims which arise out af or are in any way connected with such use. | have read and understood this consent and release. I give my consent to Crescent Academy to use my child's name and likeness as described above. Date Parent/Legat Guardian (if age 17 or below) Date Jo not give my consent to Academy Name to use my child's name and likeness a cribed above, Signature Date Parent/Legal Guardian (if age 17 or below) DateStudent Residency Form his form is intended to address the requirements of the McKinney-Vento Homeless Assistance Act (Title X, Part Cof the No Child Left Behind Act). The question below isto assist in determining if the student meets the eligibility criteria for services provided under the McKinney-Vento Act. Please Complete: Name of student(): Date of birth Date of bith: _ Date of birth: _ Date of birth: __ Date of birth: = Date of birth: Where does the student stay at night? ina shelter inamoteVaotel temporarily with more than one ‘appropriate for people (e-g,, an abandoned building) family in a house, mobile home, or apartment (because the family does not have a place of its own) student(s) are alone with no adults other (in an arrangement that is not Fixed, regular, and adequate and is not deseribed by the other choices) ata campsite placed in temporary foster care If none of the above apply: Please Check Box: [_] Under penalty of perjury under the laws of this state, I declare that the information : provided here is true and correct and of my own personal knowledge and that, if called upon to testify, I would be competent to do so. ‘Name of person completing the form: _ Signa Address: Phone number: ccan be reached for emergenci E-mail addres