infant – k4 enrollment application · 12/5/2015 · academy infant-k4 application . this child...

FREQUENTLY ASKED QUESTIONS AND ANSWERS

INFANT – K4 ENROLLMENT APPLICATION 51 Senoia Road, Fairburn, GA 30213. (770) 969-2040 Ext. 103

Email: [email protected] www.harvestrain.org

“Excellence in Education & Empowering Generations”

When can I register my Child?

Registration is ongoing throughout the school year. If there is no space available, you will be placed on the waiting list.

How do I register my Child? PARENTS MUST COMPLETE EACH DOCUMENT IN THIS APPLICATION PACKET BEFORE CHILD CAN BE ADMITTED TO THE CENTER:

1) Pick up an Enrollment Packet from the main office.

2) Complete all the forms and return them.

3) Pay registration fee and tuition.

4) Submit child’s immunization record (Georgia Form 3231) and healthy report form.

5) If applicable, submit Certificate of Ear, Eye and Dental (3years old and up). Provide proof of follow-up visit for any screening results that

indicate “Needs Further Professional Examination”; i.e., doctor’s note, scheduled appointments, information from parents, etc.

6) Obtain a copy of the center policy.

7) Submit most recent IEP for children with disabilities (updated IEP will be required once child is enrolled).

8) Sign center policy agreement.

When Do I Pay Tuition?

Tuition is due every Monday before closed of 1st shift (6:00 pm) in the main office.

How Can I become more involved?

1) Join the Parenting Committee. Meetings are held once per month. (See the Director for more information.)

2) Look out for general information and announcements that would be posted in the main office or the classroom door.

Are there any Parent-Teacher Conferences?

Parent conferences are held twice per year where development assessment of your child’s growth will be made available. Parents can also schedule

conferences any time during the year with the teachers or director to review child’s progress.

Which curriculum does the center use?

1) We use the creative curriculum and the ABEKA Curriculum.

2) You may obtain a curriculum handbook from the main office for detailed information.

What are the Tuition rates? (All DFCS subsidies accepted and Scholarship available based on income)

Program Hours of Operation: 6:30am-6:00pm

Non-refundable registration fee per year (Academy only) Book fees included Infant:$50 Toddler: $75 (T1) $90 (T2) Preschool: $100 K3:$100

K4:$125 K5: $190 1st – 3rd Grade: $360.50

Non-refundable registration fee per year (After School only) $35 Weekly Tuition K5 - $140 Weekly Tuition (Infants) $145 Weekly Tuition 1st – 3rd Grade: $162 Weekly Tuition (Toddler I & II ) $145 Weekly Tuition (Preschool) $140 Weekly Tuition (K3) $130 Weekly Tuition (K-4) $125 Weekly fee for After School Program/Leadership ($55 dollars discounted fee for ages 13 and older) $65 Summer Camp/Leadership $95-$110 Drop-in Rate (minimum 3 days only) $40

Fees include breakfast, lunch, and snack. Ten (10%) discount off tuition for oldest sibling/Specials are also offered at the beginning of school year. SCHOLARSHIPS DISCOUNT AVAILABLE FOR ALL PROGRAMS FOR LOW INCOME FAMILIES & DFCS SUBSIDIES ALSO ACCEPTED.

PARENT MUST COMPLETE A SCHOLARSHIP APPLICATION AND SUBMIT INCOME STATEMENTS TO QUALIFY.

Updated as of December 5, 2015

mailto:[email protected]

http://www.harvestrain.org/

Academy Infant-K4 Application

2

To be completed by HRA Personnel Only:

Scholarships Amount or Discounted Amount

Rate:

Reason:

Staff Initial:

ENROLLMENT FORM INFANT – KINDERGARTEN 4

(6 Weeks – 4 Years) PARENTS MUST COMPLETE EACH DOCUMENT IN THIS APPLICATION PACKET

BEFORE CHILD CAN BE ADMITTED TO THE ACADEMY. PLEASE ATTACH IMMUNIZATION RECORD AND HEALTH REPORT FORM.

(Parents Please Check One) Date of Approval:

Childcare Subsidies Start Time (6:30AM) Entrance Date:

Private Pay Pick-up Time (6PM) Withdrawal Date:

Scholarship Assistance (Indicate specific time of pick-up if different from 6pm) Reasons for Withdrawal:

Child’s First Name: Middle Initial Last Name:

Gender: Age: Race: Free Status: Reduce Status: GPA:

Grade: Birth Date: School: PTO Membership:

Home Address: City/State/Zip:

Home Telephone: County: District#

Father’s/Legal Guardian Name:

Home Address (If different from above):

City/State/Zip: County: District #

Place of Employment:

Employment Street Address: City/State/Zip:

Home Telephone:

Cell Phone:

Work Telephone:

Email Address:

Mother’s/Legal Guardian Name:

Home Street Address (If different from above): _ City/State/Zip:

Name of Place of Employment:

Employment Street Address: City/State/Zip:

Home Telephone: Work Telephone:

Cell Phone: Email Address:

Child’s Legal Guardians (Please indicate):

Both Parents Mother Father Guardian Other

Other Guardian

Child’s Living Arrangements (Please indicate):

Both Parents Mother Father

CELL PHONE CARRIER

CELL PHONE CARRIER


This child may be released to the person(s) listed below: Name of Authorized

Person Relationship Street Address City, State, Zip Code

Person(s) to contact in case of emergency, when parents cannot be reached: Please indicate the same person above if they are authorized to pick up the children

Name of Contact Person

Relationship Telephone Also Authorized to pick up my child

(Yes) (No)

Name of public or private school child attends, if any: Child’s Medical Information:

Child’s Physician: Telephone #:

Clinic Name (Primary health source): _

Does child have allergies or other physical problems, mental health disorders, mental retardation or developmental disabilities which would limit the child’s participation in the Academy’s program and activities? Yes No

Does child have allergies (insects, medications, foods, etc.): Yes No

If yes, please specify:

Are any special procedures required in caring for child? Yes No

If yes, please specify and give dates:

Under the Americans with Disabilities Act of 1991, this program is required to reasonable accommodate individuals with a disability. The reasonable accommodation requirement applies only if the program supervisor is made aware that an accommodation is required. If your child is disabled and require accommodation, you may request it at anytime. This program is also required by Federal law to provide available services without discrimination on the basis of political affiliation, religion, race, color, sex, sexual orientation, family status, national origin, nor requires religious participation, mental or physical disabilities, (including HIV infection, blindness, deafness, mobility impairments, etc.) If you believe that you have been discriminated against on the basis of the above please contact the U.S. Equal Employment Opportunity Commissions.

Signed: Parent/Legal Guardian Date

I acknowledge my electronic signature is a binding agreement to the terms of this application

3


4

1. The Harvest Rain Academy agrees to provide care for

on Name child is called by Days of week

a.m. to p.m., from to . (Month) (Month)

My child will participate in the following meal plan (circle applicable meals and snacks):

Breakfast Snack Lunch Afternoon Snack

2. Before any medication is dispensed to my child, I will provide a written authorization, which includes:date, name of child, name of medication, prescription number; and if any: dosage, date and time of daymedication is to be given. Medicine will be in the original container with my child’s name marked on it.

3. My child will not be allowed to enter or leave the facility without being escorted by the parent(s), personauthorized by parent(s), or facility personnel.

4. I acknowledge it is my responsibility to keep my child’s records current to reflect any significant changesas they occur, e.g., telephone numbers, work location, emergency contacts, child’s physician, child’shealth status, infant feeding plans and immunization records, etc.

5. The facility agrees to keep me informed of any incidents, including illnesses, injuries, adverse reactionsto medications, etc., which include my child.

6. The Harvest Rain Academy agrees to obtain written authorization from me before my child participates inroutine transportation, field trips, special activities, away from the facility, and water-related activitiesoccurring in water that is more than two feet deep.

7. I have received a copy and agree to abide by the policies and procedures for the Harvest Rain Academy.

Parent/Legal Guardian Date

Facility Administrator/Person in Charge Date

PARENTAL AGREEMENTS WITH CHILD CARE FACILITY



5

Cell Phone: Home Telephone:

Work Telephone: PARENT CONTACT INFORMATION:

Should , suffer an injury Child’s Name Date of Birth

Or illness while in the care of Harvest Rain Academy, and the facility is unable to contact me (us) immediately, it shall be authorized to secure such medical attention and care for the child as may be necessary. (We) shall assume responsibility for payment for services.

• I (we) agree to keep the facility informed of changes in telephone numbers, etc. Where I (we) can bereached.

• The facility agrees to keep me informed of changes in telephone numbers, etc. Where I (we) can bereached.

• The facility agrees to keep me informed of any incidents requiring professional medical attentioninvolving my child.

• Child’s primary source of health care is:

Physician/Clinic Name Telephone

Known medical conditions (i.e., diabetic, asthmatic, drug allergies):

Parent/Legal Guardian Date

EMERGENCY MEDICAL AUTHORIZATION

Cell Phone Carrier



6

In consideration for being accepted, for (Child’s Name)

participation in field trips, special events, daily activities, I do hereby release, forever discharge and agree to hold harmless Harvest Rain Academy and the Directors thereof from any and all liability, claims or demands for personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the participant that occur while said person is participating in the above-described trip or activity including recreation and work activities. The undersigned further hereby agrees to hold harmless and indemnify said church, its directors, employees and agents for any liability sustained by said acts of said participant, including expenses incurred attendant thereto.

The aforementioned liability statement also releases HRA and all employees/board members from any liability in the event that parents/staff violates HRC policy which prohibits the following conflict of interest actions where: 1) Parents/staff provides childcare services (on the side) for children enrolled in any of the academy’s program; 2) Dating relationship between Harvest Rain Academy staff/parents develops; and 3) Staff signing out or transporting any students enrolled in the academy (per parent permission).

The undersigned further consents to the administration of first-aid and/or doctor’s care, or any other form of medical treatment necessitated by illness or injury that may require the same. In the event of the necessity of such care or treatment as heretofore described, the undersigned agrees to hold harmless and indemnify said church, its Directors, employees and agents from any acts of malfeasance, and/or failure to act on the part of those chosen to administer medical care on behalf of the participant.

Parent/Legal Guardian

Signed this day of , 20

Insurance Company:

Policy Number:

Home Telephone:

Work Telephone:

Cell Phone:

Director’s Signature

LIABILITY RELEASE FORM


7

In an emergency and parents cannot be reached, please contact:

Child’s Name: Date Of Birth:

Address: City/State/Zip

Parent’s Name: (Father)

Home Telephone: Work Telephone: Cell Phone:

(Mother)

Home Telephone: Work Telephone: Cell Phone:

Name: Telephone:

Child’s Doctor: Telephone:

Medical Facility the center uses: Fayette Community Hospital

Address: 1255 Highway 54 West Fayetteville

City/State/Zip: Fayetteville, Georgia 30214

Child’s Allergies:

Current Prescribed Medication:

Child’s Special Medical Needs and Conditions:

In the event of an emergency involving my child, and if Harvest Rain Academy 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.

Child’s Name:

Parent/Legal Guardian: Date:

Witnessed By: Date:

VEHICLE EMERGENCY MEDICAL INFORMATION



8

Child’s Name: Start Date: _ Birth Date: Age: Please take a moment to complete this profile for your child. This information will help us know your child better and to structure a program to meet his or her individual needs.

1. Has your child had previous preschool experience?

2. What would you like most for your child to experience with us?

3. What does your child enjoy doing most?

4. Do you consider your child shy or outgoing?5. What are your child’s favorite toys?6. Does your child play with other children? Yes No

If no, please explain: 7. List the names and ages of other children in your family:

Name Age

8. What is your approximate family household income?9. What is the marital status of the child’s parents?10. Who, besides the immediate family, resides in the home?

11. What words are in your home for toileting?12. What language is spoken in your home?13. How many hours of sleep do your child usually receive a night?14. Does your child take naps? Yes No If yes, how long? 15. Does your child need a favorite item (such as a blanket) for nap? Yes No

If so, does your child have a special name for it? 16. Does your child have any special medical or physical needs? Yes No

If yes, please explain: 17. Does your child have any allergies?18. Do you have a special interest or hobby you would like to share with the children?

Yes No If so, please explain: 19. Are you available to help us with field trips or other special events? Yes No

Parent’s Signature: Date:

STUDENT PROFILE FORM



9

Child’s Name: Date of Birth:

I (Parent Name) , acknowledge that I have received a copy of the

Harvest Rain Academy Family Handbook and I agree to comply with HR policies and procedures and

Department of Human Resources (DHR) rules and regulations. I also agree to provide the center with a copy of

my child’s report card on a quarterly basis; annual CRCT report; progress reports; and a copy of their IEP (If

applicable). I agree to join the parent committee (mandatory for all parents) and pay the $10 annual

membership dues (payment plans available). I understand that failure to adhere to the HR policy and

procedures may result in suspension of service.


Photograph/Videotape Release

By signing below, I also grant Harvest Rain Academy, church, and certain entities contracted by Harvest Rain

Academy permission to record the appearance and participation of my child by photograph and/or videotape in

connection with daily academy activities for the purposes of news release, reporting, advertisement, and

assessing the progress of children and the program.

Harvest Rain Academy and its contractors are authorized to exhibit or distribute such photograph(s) and/or

videotapes in whole or in part without restrictions or limitations for educational or promotional purpose that HRA

deems appropriate. Such photograph(s) and/or video may, for example, appear in printed or visual materials

for HRA and/or HRA website, and/or HRA Facebook page. The undersigned hereby jointly and severally

releases, acquits, forgives, and discharges HRA, HRCI, and other entities contracted by HRA, from any actions,

agreements, claims, controversies, demands, judgments, liabilities, proceedings, and suits, whether arising in

equity or in law regarding such participation and appearance by said child. This release shall remain binding

upon all successors in interest and personal representative of the parties, to the extent permitted by law.


HRA PARENT HANDBOOK ACKNOWLEDGEMENT FORM ANDHRA AND DHR POLICIES AND PROCEDURES/

RULES & REGULATIONS COMPLIANCE AGREEMENT FORM




10

Bright from the Start Form 590-1-1-.20(1)

Parental Authorization: Except for first aid, 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 parent.

I give Harvest Rain Academy 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

Insect Repellent

Non-Prescription ointment (such as A & D, Desitin, Vaseline)

Baby Powder

Other (please specify)

Parent’s Signature Date

AUTHORIZATION TO DISPENSE EXTERNAL PREPARATIONS



11

SAFE SLEEP PRACTICES POLICY To be completed by Infant Birth – 12 Months Parents

Child’s name: Date of birth:

Parent/Guardian name:

Safe Sleep Practices/Policies:

1) Infants will be placed on their backs in a crib to sleep unless a physician’s written statement authorizing anothersleep position for that infant is provided. The written statement must include how the infant shall be placed tosleep and a time frame that the instructions are to be followed.

2) Cribs shall be in compliance with CPCS and ASTM safety standards. They will be maintained in good repair and freefrom hazards.

3) No objects will be placed in or on the crib with an infant. This includes, but is not limited to, covers, blankets, toys,pillows, quilts, comforters, bumper pads, sheepskins, stuffed toys, or other soft items.

4) No objects will be attached to a crib with a sleeping infant, such as, but not limited to, crib gyms, toys, mirrors andmobiles.

5) Only sleepers, sleep sacks and wearable blankets provided by the parent/guardian and that fit according to thecommercial manufacturer’s guidelines and will not slip up around the infant’s face may be worn for the comfort ofthe sleeping infant.

6) Individual crib bedding will be changed daily, or more often as needed, according to the rules. Bedding forcots/mats will be laundered daily or marked for individual use. If marked for individual use, the sheets/covers mustbe laundered weekly or more frequently if needed. This facility will adhere to the following practice:

7) Infants who arrive at the center asleep or fall asleep in other equipment, on the floor or elsewhere, will moved to asafety-approved crib for sleep.

8) Swaddling will not be permitted, unless a physician’s written statement authorizing it for a particular infant isprovided. The written statement must include instructions and a time frame for swaddling the infant.

9) Wedges, other infant positioning devices and monitors will not be permitted unless a physician’s writtenstatement authorizing its use for a particular infant is provided. The written statement must include instructions onhow to use the device and a time frame for using it.

I acknowledge that the director or designee has advised me of the safe sleep practices followed by the facility.

Parent Signature Date



12

TO BE COMPLETED BY CHILD’S PRIMARY HEALTH CARE PROVIDER

TO BE COMPLETED BY PHYSICIAN OR AUTHORIZED HEALTH CARE PROVIDER

PHYSICIAN ADDRESS HERE:

HEALTHY REPORT FORM

“Excellence in Education & Empowering Generations”

To be completed for all students birth to 3 years old and those students with special medical conditions. Please attach an allergy, asthma, and/or a seizure plan when applicable (parents may obtain one from the HRA office).

CHILD’S FULL NAME DATE OF BIRTH

This child is seeking enrollment in our Child Care/After School Program

This child will be attending our part-time or full-time programs. He or she will be in a group under the supervision of a Lead Teacher and one Assistant. The program provides general childcare services (there are no nurses or medically trained staff onsite). The daily program involves field trips (ages 4-17 years), indoor and outdoor play, active and quiet.

Has this child been diagnosed with any special medical condition? Yes No If yes, please list the name of the medical condition:

Does this child require special attention, medication, routines or have any physical condition that may have to be taken into consideration in planning for his/her time at our facility?

Please list or attach instruction for any special care needed, or in the event of emergency care that is needed:

In your opinion, is this child physically and emotionally able to participate in all activities provided by the Child Care / Preschool / After School Program?

Please attached a copy of the Georgia Department of Human Resources Certificate of Immunization From 3231 and Eye, Ear and Dental Certificates (if applicable).

PROVIDE: Physician signature, printed, typed or stamped name, address and phone number of licensed physician or Health Department.

PHYSICIAN SIGNATURE OR TODAY’S DATE HEALTHCARE PROVIDER AUTHORIZED PERSONNEL

infant – k4 enrollment application · 12/5/2015 · academy infant-k4 application . this child...

Documents