Enrollment form for RaRa Foundation

RaRa Foundation's Early Learners Program For Harris County and Surrounding Communities

Enrollment Form Date

Date

Child's Name

First NameLast Name

Date of Birth

Date

Child's Age

Gender

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Home Phone

Mother's Name

Father's Name

Mother's Employer

Father's Employer

Mother's Work Phone

Work Hours

Father's Work Phone

Work Hours

Email Address

example@example.com

Cell Phone(s) of Mother

Cell Phone(s) of Father

Person other than parent to be notified in an emergency situation when parents are not available:

Name

Phone

Address

Name(s) of person(s) other than parent to whom the child may be released:

1.

Phone

2.

Phone

3.

Phone

4.

Phone

Persons unable to pick up child(ren)

Other things staff of RaRa should be aware of:

I have read the Rules & Regulations of RaRa's Early Learners Program and agree to all Policies and Procedures.

Parent(s) Signature

PERMISSION AND AUTHORIZATION FORM

Transportation:

I give my permission for authorized RARA Staff to transport my child to and away from program headquarters, If necessary, I also give permission to RARA Staff to transport my child in a personally owned vehicle in case of an emergency.

My child will be

A Car Rider to and from The Early Learners ProgramWalk to and from The Early Learners Program with Designated RelativeA Virtual Participant of The Early Learners Program

Emergency Medical Care: I hereby give my permission to program staff to call for medical or surgical care for my child should an emergency arise. It is understood that a conscientious effort will be made to locate me before emergency action will be taken. I will accept responsibility for the expenses of emergency treatment and/or care.

YesNo

Administer Medication: (if applicable- only necessary if your child takes medication) RARA will not administer medication of any type for any child. If child is sick then parent will be notified in order for child to be picked up from the program on that day. A sick child will not be allowed to attend program during his or her illness. Children out sick will only be permitted to return to the program once a doctor's permission slip has been received and placed on file.

Waiver/Release

I give permission for my child to attend field trips and be able to participate either by foot or or by vehicle. I understand that my son/daughter is not required to attend any field trips. I agree to release FFCC and RaRa Foundation Inc. and each of their officials, officers, and employees from liability for any and all claims of injury which might occur while my son/daughter is participating in the field trip activities.

I give my permission for my child to be photographed and or recorded by program staff and/or local press as he/she is engaged in program activities for the purpose of program promotion and communication.

Nutrition Program I give my permission for my child to take part in nutrition program as part of RaRa Foundation's Early Learners Program.

Bible Study I give my permission for my child to take part in Bible Study during Early Learners Program hours.

I give my permission for my child to take part in Theater during Early Learners Program.

I give my permission for my child to take part in Finance for Youth during Early Learners Program.

I give my permission for my child to take part in Dance & Music activities during Early Learners Program.

Spanish I give my permission for my child to take part in Spanish during Early Learners Program.

I give my permission for my child to take part in Arts and Crafts during Early Learners Program.

Sign Language I give my permission for my child to take part in Sign Language during Early Learners Program.

I give permission for my child to watch the following rated movies: G Rated

Indoor/Outdoor activities I give my permission for my child to take part in various activities including but not limited to (kickball, hopscotch, jump rope, etc.)

This Permission and Authorization form will be effective from the date signed below, up to one year. I understand that I may, at any time, revoke this Permission and Authorization form by submitting written notification to RARA staff.

Parent Signature

Date

Please write down anything that you do not give permission or authorization for in the space below:

Parent Signature

Date

Type of Facility:Early Learners Program is an Educational Facility(Private)

Signed dated statement of the child's current health status which indicates the abilities and/or limitations to participate in an Early Learners Program. This report is to be filled out by a parent or legal guardian of the child. Child's Name: Sex:

Child's Name

Sex

Date of birth

Date

Address

Past Illness- child has had and give approximate dates

Chicken Pox

Ruseola

Rubella

Rheumatic Fever

Asthma

Hay Fever

Diabetes

Mumps

Epilepsy

Whooping Cough

Poliomyelitis

Other

Comments

Describe any physical or medical condition requiring special attention

Medication(s) prescribed

Allergies

If tuberculin test given: Date: Results:

Date

Results

Vision

Hearing

Date of most recent examination of the child

Date

Professional

Hospital preferred for emergency treatment

Health Insurance Company: #: Please record immunizations and dates administered on the Texas Department of Health Certification of Immunization and attach to this form.

File Upload for Immunization Record

STATEMENT OF EXEMPTION TO IMMUNIZATION LAW IN THE EVENT OF AN OUTBREAK, EXEMPTED PERSONS WILL BE SUBJECT TO EXCLUSION FROM PROGRAM AND QUARANTINE.

MEDICAL EXEMPTION THE PHYSICAL CONDITION OF THE ABOVE-NAMED PERSON IS SUCH THAT IMMUNIZATION WOULD ENDANGER LIFE OR HEALTH, OR IS MEDICALLY CONTRADICTED DUE TO OTHER MEDICAL CONDITIONS.

SIGNED

DATE

Date

(PHYSICIAN)

Parent or Guardian of the Above-Named Person or the Person Himself/Herself Adheres to a religious belief opposed to immunizations.

YOUR RIGHTS AND RESPONSIBILITIES

Students and parents should read the following information together and sign below:

You have the right to: A safe RARA experience and environment

Make choices

Your own thoughts and ideas

Be treated fairly

Be yourself

You are responsible for:

Maintaining a safe RARA experience and environment

The consequence of your choices

Respecting Others

Your own actions

CODE OF CONDUCT

As a participant in RARA I will: Respect self, others, and the environment

Arrive prepared and willing to participate with a positive, can-do attitude

Do all I can to make sure everyone (myself included) has a great RARA experience

General Rules:

You must always get permission from your teacher and or group leader to leave the room or group

Always wash your hands thoroughly with soap after going to the bathroom, before eating, after playing or before and after preparing food

Always keep your hands and feet to yourself

No rough play, foul language, or fighting will be tolerated.

No throwing of any objects unless it is part of a game or activity

Clean up after yourself

Discipline Policy:

RARA's discipline protocol consists of a color/consequence progression using three increments: green, yellow, and red. All students have name cards that upon arrival are placed under the green "attendance" card. RARA wants students to focus on self-control and positive change, however, students who demonstrate repeated or excessive negative behavior will be asked to move their name to the yellow card representing an "official" warning.

Students do have the opportunity to earn their way back to green through positive behavior. As a final consequence, persistent negative behavior results in moving to the red card requiring an indefinite timeout and communication with parent/guardian. Depending on the circumstances and severity of the behavior, this communication may take place immediately or may wait until pickup. As a last resort and at the discretion of the Program Director students who repeatedly receive red cards may not be allowed to continue to attend the program. There will be a discussion of the decision between parents and RaRa staff.

I understand that my conduct should always be appropriate to the standards of RaRa and that failure to follow these guidelines may result in my dismissal from the program. Staff will counsel students whenever possible to avoid dismissal.

I have read and understand the conditions of this agreement.

Parent Signature

Date

(Optional) Reading Mastery Program The Pre-K and Kindergartners of RaRa Foundation will begin the Reading Mastery Program to help with alphabet recognition and phonic sounds. The Program is taught via Direct Instruction. Students will be grouped according to results of his or her placement test scores. Teachers will be recorded during teaching of lessons. These recordings will be a part of an Action Research Proposal proving that the Reading Mastery Program can be used with Pre-K and Kindergartners, as well as, first and second graders, to increase comprehension skills when accompanied with decoding skills, phonics, vocabulary, phonemic awareness and other basic reading skills. Student's comprehension skills will be measured, tracked and recorded. Please note that recordings will be used as Professional Development Tapes for teachers also. Recordings will take place within the classroom during reading time for the student. Each recording will be approximately 35 to 60 minutes. Please sign below giving RaRa Foundation permission to record your child during reading class time when using the Reading Mastery Program.

(Printed Name of Parent or Guardian)

I give RaRa Foundation permission to record

my child, {childsName}

(Child's Printed Name)

Proposal, to prove that the Reading Mastery Program can be used to increase the comprehension skills of students when students have, or are being taught decoding skills, vocabulary, phonics, phonemic awareness and other basic reading skills.

Signature

Date

RELIGIOUS EXEMPTION

(PARENT OR GUARDIAN OR EMANCIPATED STUDENT/CONSENTING MINOR)