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.
STUDENT ENROLLMENT FORM
Learning Center
*
Roodner Court
Colonial Village
20 West
King Kennedy
How did you hear about the NHA learning center program?
Date of Application
*
-
Month
-
Day
Year
Date
Date of Enrollment
-
Month
-
Day
Year
Date
Last Day of Enrollment
*
-
Month
-
Day
Year
Date
Child's Name
*
First Name
Last Name
DOB
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Age
*
Grade
*
Sex
*
School
*
Does your child have an IEP (INDIVIDUALIZED EDUCATION PLAN)?
*
Yes
No
Is your child an ELL student( EARLY LANGUAGE LEARNER)?
*
Yes
No
Race
*
Black
White
Asian
Other
Ethnicity
*
Hispanic
Non Hispanic
Family Status
*
Two Parent household
Single Parent household
Parent Information
Mother's Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mother's Phone Number
-
Area Code
Phone Number
Email
example@example.com
Are you currently employed?
Yes
No
Mother's Employer Name
Mother's Employer Information
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Father's Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Father's Phone Number
-
Area Code
Phone Number
Are you currently employed?
Yes
No
Father's Employer Name
Father's Employer Information
Street Address
Street Address Line 2
City
State / 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.
*
Monday
Tuesday
Wednesday
Thursday
Friday
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 Name
Last Name
Relationship to the child
*
Phone Number
*
-
Area Code
Phone Number
Name
First Name
Last Name
Relationship to the child
Phone Number
-
Area Code
Phone Number
Name
First Name
Last Name
Relationship to the child
Phone Number
-
Area Code
Phone Number
MEDICAL INFORMATION
Health Assessment Record
Does your child have any known allergies?
*
Yes
No
Known Allergies:
Health/Medical Condition
Insurance Carrier
*
Insurance ID#
*
Telephone Number
Physician's Information
*
Name
Address
City
Phone
Postal / Zip Code
Physician Phone
Dentist Information
*
Street Address
Street Address Line 2
City
Phone
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
*
-
Month
-
Day
Year
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
*
-
Month
-
Day
Year
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
*
-
Month
-
Day
Year
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
*
-
Month
-
Day
Year
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
-
Month
-
Day
Year
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 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. Ifurther release all rights to any claims to use of these photographs or videosto 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 forany 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
*
I accept
I DO Not accept
Date
*
-
Month
-
Day
Year
Date
Type a question
Submit
Should be Empty: