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Registration Packet/ Forms

 

Registration Form - Friedens Early Learning Academy (FELA) 2014-15

2555 Friedens Church Road, Seguin Texas 78155. 830-303-7729. www.friedensearlylearningacademy.org

 

CHILD’S NAME: __________________________     BIRTHDATE: _________________                              

Home Address: ________________________           City/Zip:_________________________                                          

Home Phone:  ____________________________     Admission Date:_________________    

E-Mail Address:______________________________________ Work email_____________________

MOTHER/GUARDIAN

Name:                                                          

Employer:                                                    

Work Phone:                                               

Cell:                                                             

Driver’s License #:                                    

 

FATHER/GUARDIAN

    Name:                                                       

    Employer:                                                 

    Work Phone:                                                                     

    Cell:                                                           

    Driver’s License #:                                  

One contact, other than the parents, is required for registration. If the parents are unavailable, the following individual has permission to transport and seek care for this child.

Name                             Drivers License#                Address                                      Phone (work/home/cell)

_________________________________________________________________________________________________

The following people are only authorized to pick up this child.

Name/Address                                                                          Driver’s License#                   Phone (work/home/cell)    

                              _______________________________________________________________________________    

____________________________________________________________________________________________

____________________________________________________________________________________________ 

____________________________________________________________________________________________

 

My child is normally in care on the following days and times:

*      Mondays                     from:                                       to:

*      Tuesdays                     from:                                       to:

*      Wednesdays               from:                                       to:

*      Thursdays                   from:                                       to:

*      Fridays                        from:                                       to

 

Emergency Medical Release: In the event that I cannot be reached or cannot make arrangements for emergency medical attention at the time of illness or accident I hereby authorize this facility to transport my child to the closest medical facility and authorize the medical providers to provide necessary treatment.

Doctor                                                               Address ______________________________________       Phone ______________

Parent/Guardian Signature                                                                                               

ALLERGIES: Child is known to have allergic reactions to:

Allergen               Reaction                                       Best way for FELA to handle

                                                                                                                                                   __________________

 

                                                                                                                                                  __________________

 

                                                                                                                                                   __________________                       

 

 

Parent/Guardian Signature________________________                                 Date    ________________                

                                                                                              General Health Information

Child’s Name:  ___________________________________                                                                                                                     

 

MEDICAL CONDITIONS: Describe any medical conditions that your child may have, and how you would like our staff to respond. Please include any past serious illnesses or injuries, disabilities, and hospitalizations that have occurred in the past 12 months.

Medical Condition                                                          Best way for FELA to handle

_________________________________________________________________________________________________

_____________________________________________________________________________________________          

__________________________________________________________________________________________________

__________________________________________________________________________________________________

MEDICATIONS: Please list any medication prescribed for long-term, continuous use

__________________________________________________________________________________________________

__________________________________________________________________________________________________

Medication Authorization

Should my child require medication brought from home, I authorize FELA staff to administer this medication to my child. I understand that I must fill out and sign a medication form that is kept in the FELA office.  I understand that all medication must be in the original container and labeled appropriately.  This includes first and last name of child and amount to be given.  I understand that I am responsible for providing a measuring device to administer the medication.

Parent/Guardian Signature  ____________________________                                                                                             

Well Check

I understand that a requirement for participation in this program is a doctor’s examination every 12 months. I understand that I must present a statement each year from my child’s doctor within one week of admission to verify that he or she is physically able to participate in the day care program.

Parent/Guardian Signature______________________________                                                                                                                                

Full Day

18 mo.-2 yrs.

3-4yrs.

 

5 days a week

505.00

490.00

Mon., Wed., Fri.

325.00

315.00

Tue., Thu.

225.00

215.00

 

Half Day

18 mo.-2 yrs.

3-4 yrs.

 

5 days a week

275.00

265..00

Mon., Wed., Fri.

170.00

165.00

Tue., Thu.

120.00

115.00

 

Preschool Drop-off

5 days a week                                                                         330.00

FAST

5 days a week                                                                         175.00

Drop-In Rate      Full Day--$40       Half Day--$25        (for registered students only)

10% discount for second, third child

 

Photo Release

 

 

I________________________________give permission for my child, _______________________’s

Photograph to be used in advertising projects such as brochures, postcards, and online sites such as

the churches webpage and Facebook.

 

 

_____________________________________________________date_______________________