application for enrollment st. andrew’s by-the-sea preschool

Application for Enrollment

St. Andrew’s by-the-Sea Preschool Date __________________ Child’s Name ________________________________________

Date of Birth ________________ Phone number _____________________________

Address ________________________________________________________________

Parent ______________________________ Cell number _________________________

Work number ________________________ Email ______________________________

Parent ______________________________ Cell number _________________________

Work number ________________________ Email ______________________________

Class preference: Potential Start Date: _______________________

____ Jellyfish (DOB July 2013-Dec 2013) ____ Starfish (DOB Jan 2013-June 2013)

____ Dolphins (DOB July 2012-Dec 2012) ____ Sea Horse (DOB Jan 2012-June 2012)

____ Sea Turtle (DOB Jan 2011-Dec 2011) ____ OceanExp (DOB Sep 2010-Aug2011)

Days Enrolled 5 DAYS MTWTHF ____ 3 DAYS MWF ____ 2 DAYS TTH ____

Half day ____ Full day ____ *special arrangements based on availability

I agree to:

All of the above contact and enrollment information is correct.

Pay of $125 is required for a non-refundable application/registration fee.

Notify the Director prior to my child’s start date of any change in my

child’s enrollment.

Print Name ______________________________________________________________

Signature ________________________________________Date ___________________

FOR OFFICE USE ONLY

__ Enrollment Packet given __ Preschool t-shirt given Size _____

__ Registration fees received __ Welcome packet received

__ First month tuition received

Registration fee: Date ________________ Tuition fee paid ___________________

Amount _____________ Amount _________________________

Check #/CASH _______ Check #/CASH ___________________

Staff Initials ________ Referred by ______________________

Financial Agreement

St. Andrew’s by-the-Sea Preschool

Tuition is based on a 10- month year and is therefore the same every month

regardless of the number of school days, holidays or child’s absences. A 2-week

paid notice is required if you withdraw your child at any time.

Tuition is due in advance. A 10% late fee will be added to a balance that is five (5)

days past due. If tuition is more than ten (10) days past due, a child will not be

allowed to continue in the program until payment is paid in full.

Name of Child__________________________________________________________________

The hours my child will attend are: Half day (8:30-12:30) ____ Full day (7:30-5:30) ____

The days my child will attend are: TTH ____ MWF ____ M-F ____

My child’s first day at St. Andrew’s by-the-Sea will be:____________________________ date

The monthly tuition for this schedule is:______________________________________________ to be filled in by the preschool director

The tuition payment for my child will be made: (check one)

__________ Once a month (due on the 1st of each month)

__________ Twice a month (due on the 1st and the 15th of each month)

Name of person(s) responsible for payment: (please print)

__________________________________________________________________

__________________________________________________________________

(Should either party fail to pay his/her share of the tuition, the other party will be responsible

for the entire amount).

I/We understand the rules regarding payment of tuition and I/we agree to abide by these policies.

(If more than one person has financial responsibility, both must sign below.)

____________________________________________________________________________

Signature Date

____________________________________________________________________________

Signature Date

Rev 4/12

PHYSICIAN OR DENTIST TO BE CALLED IN AN EMERGENCY

NAMES OF PERSONS AUTHORIZED TO TAKE CHILD FROM THE FACILITY(CHILD WILL NOT BE ALLOWED TO LEAVE WITH ANY OTHER PERSON WITHOUT WRITTEN AUTHORIZATION FROM PARENT OR AUTHORIZED REPRESENTATIVE)

TO BE COMPLETED BY FACILITY DIRECTOR/ADMINISTRATOR/FAMILY CHILD CARE HOMES LICENSEE

STATE OF CALIFORNIAHEALTH AND HUMAN SERVICES AGENCY

CALIFORNIA DEPARTMENT OF SOCIAL SERVICESCOMMUNITY CARE LICENSING DIVISION

IDENTIFICATION AND EMERGENCY INFORMATIONCHILD CARE CENTERS/FAMILY CHILD CARE HOMESTo Be Completed by Parent or Authorized Representative

CHILD’S NAME LAST MIDDLE FIRST

ADDRESS NUMBER STREET CITY STATE ZIP

FATHER’S/GUARDIAN’S/FATHER’S DOMESTIC PARTNER’S NAME LAST MIDDLE FIRST

HOME ADDRESS NUMBER STREET CITY STATE ZIP

MOTHER’S/GUARDIAN’S/MOTHER’S DOMESTIC PARTNER’S NAME LAST MIDDLE FIRST

HOME ADDRESS NUMBER STREET CITY STATE ZIP

PERSON RESPONSIBLE FOR CHILD LAST NAME MIDDLE FIRST

PHYSICIAN ADDRESS MEDICAL PLAN AND NUMBER

DENTIST ADDRESS MEDICAL PLAN AND NUMBER

TIME CHILD WILL BE CALLED FOR

SIGNATURE OF PARENT/GUARDIAN OR AUTHORIZED REPRESENTATIVE

DATE OF ADMISSION

IF PHYSICIAN CANNOT BE REACHED, WHAT ACTION SHOULD BE TAKEN?

■■ CALL EMERGENCY HOSPITAL ■■ OTHER EXPLAIN: ____________________________________________________________________________________________________________________

NAME

NAME

ADDRESS TELEPHONE RELATIONSHIP

RELATIONSHIP

SEX

HOME TELEPHONE

( )

TELEPHONE

( )

TELEPHONE

( )TELEPHONE

( )

DATE

DATE LEFT

BIRTHDATE

BUSINESS TELEPHONE

( )

BUSINESS TELEPHONE

( )

BUSINESS TELEPHONE

( )

HOME TELEPHONE

( )

HOME TELEPHONE

( )

ADDITIONAL PERSONS WHO MAY BE CALLED IN AN EMERGENCY

LIC 700 (8/08)(CONFIDENTIAL)

( )( )

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

CONSENT FOR EMERGENCY MEDICAL TREATMENT-Child Care Centers Or Family Child Care Homes

AS THE PARENT OR AUTHORIZED REPRESENTATIVE, I HEREBY GIVE CONSENT TO

_________________________________________ TO OBTAIN ALL EMERGENCY MEDICAL OR DENTAL CARE FACILITY NAME

PRESCRIBED BY A DULY LICENSED PHYSICIAN (M.D.) OSTEOPATH (D.O.) OR DENTIST (D.D.S.) FOR

__________________________________________________ . THIS CARE MAY BE GIVEN UNDER NAME

WHATEVER CONDITIONS ARE NECESSARY TO PRESERVE THE LIFE, LIMB OR WELL BEING OF THE CHILD

NAMED ABOVE.

DATE PARENT OR AUTHORIZED REPRESENTATIVE SIGNATURE

CHILD HAS THE FOLLOWING MEDICATION ALLERGIES:

HOME ADDRESS

HOME PHONE

LIC 627 (9/08) (CONFIDENTIAL)

WORK PHONE

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

PERSONAL RIGHTSChild Care Centers

Personal Rights, See Section 101223 for waiver conditions applicable to Child Care Centers.(a) Child Care Centers. Each child receiving services from a Child Care Center shall have rights which include, but are

not limited to, the following:

(1) To be accorded dignity in his/her personal relationships with staff and other persons.

(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/herneeds.

(3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion,threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with dailyliving functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids tophysical functioning.

(4) To be informed, and to have his/her authorized representative, if any, informed by the licensee of theprovisions of law regarding complaints including, but not limited to, the address and telephone number of thecomplaint receiving unit of the licensing agency and of information regarding confidentiality.

(5) To be free to attend religious services or activities of his/her choice and to have visits from the spiritual advisorof his/her choice. Attendance at religious services, either in or outside the facility, shall be on a completelyvoluntary basis. In Child Care Centers, decisions concerning attendance at religious services or visits fromspiritual advisors shall be made by the parent(s), or guardian(s) of the child.

(6) Not to be locked in any room, building, or facility premises by day or night.

(7) Not to be placed in any restraining device, except a supportive restraint approved in advance by the licensingagency.

THE REPRESENTATIVE/PARENT/GUARDIAN HAS THE RIGHT TO BE INFORMED OF THE APPROPRIATELICENSING AGENCY TO CONTACT REGARDING COMPLAINTS, WHICH IS:

NAME

(PRINT THE NAME OF THE FACILITY)

(PRINT THE NAME OF THE CHILD)

(SIGNATURE OF THE REPRESENTATIVE/PARENT/GUARDIAN)

(TITLE OF THE REPRESENTATIVE/PARENT/GUARDIAN) (DATE)

LIC 613A (8/08)

(PRINT THE ADDRESS OF THE FACILITY)

ADDRESS

CITY ZIP CODE AREA CODE/TELEPHONE NUMBER

DETACH HERE

TO: PARENT/GUARDIAN/CHILD OR AUTHORIZED REPRESENTATIVE: PLACE IN CHILD'S FILE

Upon satisfactory and full disclosure of the personal rights as explained, complete the following acknowledgment:

ACKNOWLEDGMENT: I/We have been personally advised of, and have received a copy of the personal rights contained in theCalifornia Code of Regulations, Title 22, at the time of admission to:

STATE OF CALIFORNIA—HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICESCOMMUNITY CARE LICENSING DIVISION

CHILD CARE CENTERNOTIFICATION OF PARENTS’ RIGHTS

PARENTS’ RIGHTSAs a Parent/Authorized Representative, you have the right to:

1. Enter and inspect the child care center without advance notice whenever children are in care.

2. File a complaint against the licensee with the licensing office and review the licensee’s public filekept by the licensing office.

3. Review, at the child care center, reports of licensing visits and substantiated complaints against thelicensee made during the last three years.

4. Complain to the licensing office and inspect the child care center without discrimination or retaliationagainst you or your child.

5. Request in writing that a parent not be allowed to visit your child or take your child from the childcare center, provided you have shown a certified copy of a court order.

6. Receive from the licensee the name, address and telephone number of the local licensing office.

Licensing Office Name: _________________________________________________

Licensing Office Address: _________________________________________________

Licensing Office Telephone #: _________________________________________________

7. Be informed by the licensee, upon request, of the name and type of association to the child carecenter for any adult who has been granted a criminal record exemption, and that the name of theperson may also be obtained by contacting the local licensing office.

8. Receive, from the licensee, the Caregiver Background Check Process form.

NOTE: CALIFORNIA STATE LAW PROVIDES THAT THE LICENSEE MAY DENY ACCESS TO THE CHILD CARE CENTER TO APARENT/AUTHORIZED REPRESENTATIVE IF THE BEHAVIOR OF THE PARENT/AUTHORIZED REPRESENTATIVEPOSES A RISK TO CHILDREN IN CARE.

LIC 995 (9/08) (Detach Here - Give Upper Portion to Parents)

AC K N OW L E D G E M E N T O F N OT I F I C AT I O N O F PA R E N T S ’ R I G H T S (Parent/Authorized Representative Signature Required)

I, the parent/authorized representative of ________________________________________________, havereceived a copy of the “CHILD CARE CENTER NOTIFICATION OF PARENTS’ RIGHTS” and theCAREGIVER BACKGROUND CHECK PROCESS form from the licensee.

_____________________________________Name of Child Care Center

______________________________________________ __________________Signature (Parent/Authorized Representative) Date

NOTE: This Acknowledgement must be kept in child’s file and a copy of the Notification given toparent/authorized representative.

LIC 995 (9/08)

For the Department of Justice “Registered Sex Offender”database, go to www.meganslaw.ca.gov

For the Department of Justice “Registered Sex Offender”database go to www.meganslaw.ca.gov

I have ■■ have not ■■ reviewed the above information with the parent/guardian.

Physician:_______________________________________________ Date of Physical Exam: ___________________________________Address:________________________________________________ Date This Form Completed: _______________________________Telephone: ______________________________________________ Signature ______________________________________________

■■ Physician ■■ Physician’s Assistant ■■ Nurse Practitioner

DATE EACH DOSE WAS GIVEN

/ /

/ /

IMMUNIZATION HISTORY: (Fill out or enclose California Immunization Record, PM-298.)

PHYSICIAN’S REPORT—CHILD CARE CENTERS(CHILD’S PRE-ADMISSION HEALTH EVALUATION)

PART A – PARENT’S CONSENT (TO BE COMPLETED BY PARENT)

__________________________________________, born ________________________________ is being studied for readiness to enter(NAME OF CHILD) (BIRTH DATE)

_________________________________________ . This Child Care Center/School provides a program which extends from _____ : ____(NAME OF CHILD CARE CENTER/SCHOOL)

a.m./p.m. to ______ a.m./p.m. , __________ days a week.

Please provide a report on above-named child using the form below. I hereby authorize release of medical information contained in thisreport to the above-named Child Care Center.

__________________________________________________________ _________________(SIGNATURE OF PARENT, GUARDIAN, OR CHILD’S AUTHORIZED REPRESENTATIVE) (TODAY’S DATE)

PART B – PHYSICIAN’S REPORT (TO BE COMPLETED BY PHYSICIAN)

Problems of which you should be aware:

Hearing: Allergies:medicine:

Vision: Insect stings:

Developmental: Food:

Language/Speech: Asthma:

Dental:

Other (Include behavioral concerns):

Comments/Explanations:

MEDICATION PRESCRIBED/SPECIAL ROUTINES/RESTRICTIONS FOR THIS CHILD:

LIC 701 (8/08) (Confidential)

1st 2nd 3rd 4th 5thVACCINE

POLIO (OPV OR IPV)

DTP/DTaP/DT/Td

MMR

HIB MENINGITIS

HEPATITIS B

VARICELLA

(DIPHTHERIA, TETANUS AND[ACELLULAR] PERTUSSIS OR TETANUSAND DIPHTHERIA ONLY)

(MEASLES, MUMPS, AND RUBELLA)

(REQUIRED FOR CHILD CARE ONLY)

(CHICKENPOX)

(HAEMOPHILUS B)

/ / / / / / / / / /

/ / / / / / / / / // / / /

/ / / / / /

/ / / // / / /

SCREENING OF TB RISK FACTORS (listing on reverse side)

■■ Risk factors not present; TB skin test not required.

■■ Risk factors present; Mantoux TB skin test performed (unless

previous positive skin test documented).___ Communicable TB disease not present.

STATE OF CALIFORNIAHEALTH AND HUMAN SERVICES AGENCY

CALIFORNIA DEPARTMENT OF SOCIAL SERVICESCOMMUNITY CARE LICENSING

PAGE 1 OF 2

RISK FACTORS FOR TB IN CHILDREN:

* Have a family member or contacts with a history of confirmed or suspected TB.

* Are in foreign-born families and from high-prevalence countries (Asia, Africa, Central and South America).

* Live in out-of-home placements.

* Have, or are suspected to have, HIV infection.

* Live with an adult with HIV seropositivity.

* Live with an adult who has been incarcerated in the last five years.

* Live among, or are frequently exposed to, individuals who are homeless, migrant farm workers, users of street drugs, or residents innursing homes.

* Have abnormalities on chest X-ray suggestive of TB.

* Have clinical evidence of TB.

Consult with your local health department’s TB control program on any aspects of TB prevention and treatment.

LIC 701 (8/08) (Confidential) PAGE 2 of 2

Preschool Family Directory

We have a Preschool Family Directory and would like to include your family in on

this. Basically we provide all families that are participating with a current list of all

the children enrolled in our preschool and include the child’s name, parent’s

name, address, phone number and email address. We do this as a way to serve as

a “preschool” networking so families can get together outside of preschool for

play dates, birthday parties, keep in contact, etc… You can choose to participate

by filling out the information below or OPT OUT by signing on that line.

CHILD’S NAME ______________________________________ CLASS __________________

PARENT’S NAME ________________________________________________________________

HOME ADDRESS ________________________________________________________________

BEST PHONE TO CALL ________________________________________________________________

EMAIL ADDRESS ________________________________________________________________

I WISH TO OPT OUT OF THE PRESCHOOL FAMILY DIRECTORY AT THIS TIME…

PRINT NAME _______________________________ SIGNATURE __________________________


Sunscreen form

I give my permission for the teachers to apply sunscreen that I have provided on my child ____________________________. Please sign below indicating your permission, with the understanding that the sunscreen you provide will be used on your child only. Make sure to label it with the full name of your child and give to your child’s classroom teacher. Parent’s name __________________________________________ Parent’s signature _______________________________________ Date ___________________________


Walking Permission Slip

I understand that my child ____________________________ may go on walking field trips in the neighborhood with the staff of St. Andrew’s by-the-Sea Preschool. The staff carries a first-aid kit, emergency telephone numbers and medical information in a backpack. A special permission slip will be sent out for any field trip requiring transportation and advance notice will be given. This permission slip is valid for the 2015-2016 school year. I have read the information above and by signing below I am giving my permission for my child to participate. Parent’s name __________________________________________ Parent’s signature _______________________________________ Date ___________________________

St. Andrew’s by-the-Sea Preschool Photo Release form

Our staff frequently takes pictures of the children throughout the day to show activities that they are

doing and/or to show progress in specific developmental areas. Each week your child’s teacher along

with the Director will email the families sharing information about weekly events and activities along

with pictures of children at our preschool. Please read and fill out each section. Thank you!

CHILD’S NAME _____________________________ PARENT’S NAME ____________________________

PHOTOS TAKEN FOR PRESCHOOL COMMUNICATION BETWEEN FAMILIES

I give my permission for my child to have his or her picture taken for the purpose of St. Andrew’s by-

the-Sea Preschool to share with current families and/or to hang up throughout the preschool.

Parent’s signature ___________________________________ Date _______________

I do not want my child’s picture taken for this purpose.


PHOTOS TAKEN FOR PRESCHOOL WEBSITE AND/OR PRESCHOOL BROCHURE






PHOTOS TAKEN FOR PRESCHOOL (PRIVATE) FACEBOOK PAGE







Stay home sick form

I understand that I must keep my child ____________________________ home if any of the following occur… --If my child has had a fever or vomited during the previous 24 hours. --If my child has been placed on prescribed medication, they need to be on it for 24 hours before returning to school. --If my child is fussy, cranky and generally not feeling well. --If my child has heavy or colored nasal discharge. --If my child has a deep, persistent cough. --If my child is not well enough to go outdoors to play. YOUR CHILD MUST BE FREE OF ALL SYMPTOMS FOR 24 HOURS BEFORE RETURNING TO SCHOOL. I know it is difficult for working parents but your child is at risk if he/she comes to school unwell as their resistance may be low or they may be coming down with a serious illness and be contagious. Please notify the school if your child is absent and particularly if he/she has a communicable disease, including but not limited to strep throat, pink eye or head lice. Please try to leave an emergency person, family member or friend available to keep your child if you cannot leave work to take care of your child. Please help us keep your child’s file up to date on phone numbers, emergency numbers and other important information. In case of accidental injury, we will make an immediate attempt to contact the child’s parents. If they are not available, we will follow the order requested by the parents on the Medical Release form. ONLY PRESCRIBED MEDICATION CAN BE ADMINISTERED AT SCHOOL If it is necessary for a staff member to administer medication, the parent MUST sign the medication form posted in the office. Parent is to indicate the amount of medicine to be given, name of the medication, time to be given and sign the form. This is to be done each day the medication is to be given. Medication must come in original bottle showing the prescription. If over-the-counter medication needs to be administered, written directions must first be obtained from the doctor. ALL MEDICATION ADMINISTERED MUST BE PRESCRIBED BY DOCTOR, THIS IS THE STATE LAW.

Parent’s name __________________________________________ Parent’s signature _______________________________________ Date ___________________________

EMERGENCY PROCEDURES & EVACUATION PLAN St. Andrew’s by-the-Sea Preschool conducts Fire and Earthquake drills on a regular

basis and has emergency kits with food, water and emergency supplies in all

classrooms. In the event of an emergency during school hours these are the

procedures we will take to ensure the safety of all children. Director will contact

Emergency Preparation Committee and they will contact the families on their list

via text and/or email. Please be sure that all records are kept up to date.

POINTS OF RELOCATION:

Pacific Beach Library

4275 Cass Street

San Diego, CA 92109

858-581-9934

Kate Sessions Elementary School

2150 Beryl Street

San Diego, CA 92109

858-273-3111

Pacific Beach Recreation Center

1405 Diamond Street

San Diego, CA 92109

858-581-9927

************************************************************************* Please print, sign, date and return this bottom portion to the Director at enrollment.

Print name _________________________ Child’s name _____________________

Signature __________________________ Date __________________________

application for enrollment st. andrew’s by-the-sea preschool

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