Enrollment Form

NORWALK HOUSING AUTHORITY LEARNING CENTER ENROLLMENT
Mission Statement

The Norwalk Housing Authority Learning Centers are committed to providing our student residents with academic support and enrichment opportunities in a safe, comfortable environment that empowers children to reach their highest potential and launch successfully into adulthood.
Mission Statement (Hatian Creole)

Sant Aprantisaj Norwalk Housing Authority pran angajman pou bay elèv ki abite nou yo sipò akademik ak opòtinite anrichisman nan yon anviwonman ki an sekirite, konfòtab ki pèmèt timoun yo rive jwenn pi gwo potansyèl yo epi lanse avèk siksè nan laj granmoun.
Mission Statement (Spanish)

Los Centros de Aprendizaje de la Autoridad de Vivienda de Norwalk están comprometidos a brindar a nuestros estudiantes residentes apoyo académico y oportunidades de enriquecimiento en un ambiente seguro y cómodo que capacite a los niños para alcanzar su máximo potencial y lanzarse exitosamente a la edad adulta.
STUDENT ENROLLMENT FORM
Learning Center*

Roodner CourtColonial Village20 West
If you require transportation to the learning center, please get in touch with Assistant Director Tiana Brown or Gwen Harris. Tiana Brown or Gwen Harris.

Tiana Brown email: tbrown@norwalkha.org (475) 237-2462

Gwen Harris email: gharris@norwalkha.org (203) 818-4577
How did you hear about the NHA learning center program?
Date of Application*

MonthDayYear
Date
Date of Enrollment

MonthDayYear
Date
Child's Name*

First NameLast Name
DOB*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Age *
Grade *
Sex*
School*
Does your child have an IEP (INDIVIDUALIZED EDUCATION PLAN)?*
Is your child an ELL student( EARLY LANGUAGE LEARNER)?*
Race*

BlackWhiteAsianOther
Ethnicity*

HispanicNon Hispanic
Family Status*
Parent Information
Mother's Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mother's Phone Number*

Area CodePhone Number
Email*
example@example.com
Are you currently employed?
Mother's Employer Name
Mother's Employer Information

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Father's Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Father's Phone Number

Area CodePhone Number
Are you currently employed?
Father's Employer Name
Father's Employer Information

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Weekly Care
Weekly Care Schedule: Please indicate the child's days he/she will attend the learning center. Student must attend at least 3 times per week.*

MondayTuesdayWednesdayThursdayFriday
Pick-up Procedures / Emergency Contacts

In an emergency, adults to be contacted if parents cannot be reached and to whom the child can be released
Name*

First NameLast Name
Relationship to the child*
Phone Number*

Area CodePhone Number
Name

First NameLast Name
Relationship to the child
Phone Number

Area CodePhone Number
Name

First NameLast Name
Relationship to the child
Phone Number

Area CodePhone Number
MEDICAL INFORMATION

(SPANISH) INFORMACIÓN MÉDICA (CREOLE) ENFÒMASYON MEDIKAL
Health Assessment Record
Does your child have any known allergies?*

YesNo
Known Allergies:
Health/Medical Condition
Insurance Carrier*
Insurance ID#*
Physician's Information *

Name

Address

CityPhone

Postal / Zip Code
Physician Phone
Dentist Information *

Street Address

Street Address Line 2

CityPhone

Postal / Zip Code
EMERGENCY AUTHORIZATION

I give my consent for the First Aid and CPR certified staff of the NHA Learning Centers to administer first aid and CPR to my child and to contact the above-named physician or dentist if my child has a medical emergency. I also give my consent for my child to be transported to the nearest hospital in the event of a medical emergency. I will be responsible for all medical fees.
Preferred Medical Facility: (If left blank, child will automatically go to the nearest medical facility)
Date*

MonthDayYear
Date
Emergency Authorization Signature of Parent or Guardian:*

Clear
A copy of your child's health records and immunizations MUST accompany each Learning Center Enrollment Form

As Parent/legal/guardian/conservator of Program Participant and in His/Her own Right “I give my permission for chaperones, administrators, and personnel affiliated with the Norwalk Housing Authority to seek medical attention for my child/children should they become injured. I hereby release coaches, volunteers, the Norwalk Housing Authority, and their agencies, commissioners, representatives, and employers from any and all claims with respect to any injury sustained by my child/children as a result of participation in any program sponsored by the NHA agencies.”
Child Health Record Signature of Parent or Guardian:*

Clear
Date*

MonthDayYear
Date
NHA WAIVER/PERMISSION FOR PROGRAM ENROLLMENT & RIDING ON TRANSPORTATION PROVIDED BY NHA FOR OUTSIDE FIELD TRIPS

I willingly allow my child, the Program/Event/Participant, to participate as a volunteer in enrichment/academic programs and field trips offered through Norwalk Housing Authority. I give permission for my child, the Program/Event/Participant to be transported to and from NHA sponsored programs. On behalf of my child, the Program/Event/Participant, I understand and accept the inherent risk involved in transport to and from the programs.
Transportation Signature of Parent or Guardian:*

Clear
Date*

MonthDayYear
Date
PARENT HANDBOOK

I acknowledge that I have read the parent handbook and agree to abide by the policies contained in it.
Parent Handbook Signature of Parent or Guardian:*

Clear
Date*

MonthDayYear
Date
Behavior Management Policy
Behavior Management Policy: This is to certify that I have received the Behavior Management policy and it has been discussed with me. Please sign here: *

Clear
Date

MonthDayYear
Date
PHOTOS & PRESS RELEASE FORM

I have the legal right to agree to allow the photographing of my child/ward with the understanding that the resulting photographs or videos may be used by the Housing Authority and the Norwalk Housing Foundation, Inc., and reproduced for the Norwalk Housing Foundation, Inc., Scholarship Program and the Norwalk Housing Authority Annual report. I further release all rights to any claims to use these photographs or videos to the Norwalk Housing Authority and the Norwalk Housing Foundation, Inc. I further give my permission the Norwalk Housing Authority and the Norwalk Housing Foundation, Inc., to use the photographs or videos taken of my child/ward with correct name or without name for any other promotional materials in print, video, website, press release, poster, or any other media format that the Norwalk Housing Authority and/or Norwalk Housing Foundation, Inc. may decide to employ for information distribution, program promotion, fundraising, publicity, college scholarship campaigns,or other purposes. I also give permission for the press/media and Norwalk Housing Authority promotional representatives to interview my child/ward and use any and all material from such interviews with credit given by name to my child/ward as deemed needed in all articles or segments produced in relation to such interviews in all media, print, and broadcast formats including print news and promotional venues, television, radio, video, and web casts with regard to any and all programs sponsored by the Norwalk Housing Authority or Norwalk Housing Foundation, Inc.
Photos and Press Release agreement *
Date*

MonthDayYear
Date
Type a question
Signature

Clear
Should be Empty:

NORWALK HOUSING AUTHORITY LEARNING CENTER ENROLLMENT

Mission Statement

Mission Statement (Hatian Creole)

Mission Statement (Spanish)

STUDENT ENROLLMENT FORM

Parent Information

Weekly Care

Pick-up Procedures / Emergency Contacts

MEDICAL INFORMATION

EMERGENCY AUTHORIZATION

A copy of your child's health records and immunizations MUST accompany each Learning Center Enrollment Form

NHA WAIVER/PERMISSION FOR PROGRAM ENROLLMENT & RIDING ON TRANSPORTATION PROVIDED BY NHA FOR OUTSIDE FIELD TRIPS

PARENT HANDBOOK

Behavior Management Policy

PHOTOS & PRESS RELEASE FORM