NLC Student Application (3)

Check the box if it applies:

I have paid the $25 Application Fee

Pre-Placement Tour Date

Date

Today's Date*

Date

Desired date of admission*

Date

Birth date of child

Date

What does your child like to be called

Parent #1 Name

Address

Home phone number

Cell Phone Number

Work Phone Number

Employed at

Typical work hours

Email address

example@example.com

Social Security Number (last 4 digits) Parent #2 Name

Social Security Number (last 4 digits)

Parent #2 Name

Address

Home Phone Number

Work Phone Number

Cell Phone Number

Employed at

Typical work hours

Email address

example@example.com

Social Security Number (last 4 digits)

Emergency Contact's name

Emergency Contact's Address

Emergency Contact's Home Phone

Emergency Contact's Cell Phone

Emergency Contact's Work Phone

Employed at

Email address

example@example.com

Vaccination Policy For the safety of all children attending NLC. we require that all students be up to date on vaccinations. Parents must supply us with an up-to-date vaccination record upon starting school.

Transportation Plan To ensure the safety of your child, please list the adults who are authorized to pick up your child on a regular basis. Please notify the teacher or office any time someone other than the child's legal guardian will pick them up. Otherwise, we will not release them until we have contacted a legal guardian and received verbal permission.

To ensure the safety of your child, please list the adults who are authorized to pick up your child on a regular basis. Please notify the teacher or office any time someone other than the child's legal guardian will pick them up. Otherwise, we will not release them until we have contacted a legal guardian and received verbal permission.

Please list your insurance information. We have secondary insurance coverage for your child in case of an emergency. Our provider requires that we have listed the company of the child's primary coverage. Subscriber's name

Subscriber's name

Company Policy ID number Phone number

Company

Policy ID number

Physician Information Name of physician Office phone number Other Children in Family Name

Name of physician

Other Children in Family

What are some of the ways in which your child plays at home?

Does he/she play with other children?

Does he/she usually get his/her own way with other children?

If not. how does he/she react?

Is the entire family together for any time during the day?

At what time does your child eat? Lunch

Breakfast

Lunch

Snack

What is your child's attitude towards eating?

If he/she refuses to eat, how is this handled and by whom?

Favorite foods are

Disliked foods are

Foods he/she is allergic to

Please list any other information we should know

Northside Learning Center Child's Health History

Child's name

Child's birth date

Date

Parent's signature Parent's signature

Parent's signature

The answer to these questions will help us to know if your child has any medical problems. We need this information in case he/she becomes ill and we are unable to reach you right away. Please circle the right answer.

Pregnancy and Birth Y N Were there any problems with pregnancy or your child's birth? YN Was his/her birth weight under 5 and half pounds? Y N Did the baby have any problems in the hospital? If so, explain.

N

Did the baby have any problems in the hospital? If so, explain.

Y N Has your child even been in the hospital overnight? If so, explain.

N Has your child even been in the hospital overnight? If so, explain.

Y N Is your child taking medicine? If so, explain.

N Is your child taking medicine? If so, explain.

Y N Any allergies or reaction to medicine, DTP, shots, or insects?

Y N Has your child had asthma or wheezing? Y N Does your child have a speech problem? If so, please describe.

Y

Y N Does your child have a hearing problem? If so, please describe.

Y N Has your child had two or more ear infection in a year? Y N Does your child have tubes in his/her ears? Y N Has your child had tonsillitis? Y N Does your child have trouble with his/her eyes? If so, please describe.

N

Y

Y N Has your child ever had a bladder or kidney infection? If so, please describe.

N

Y N Does your child have a burning sensation when urinating? Y N Does your child have seizures, fits, or shaking spells? If so, please explain?

N

Y

Y N Have you been told that your child has a heart murmur? If so, please explain?

Y N Is your child on a heart monitor? Y N Is your child able to play as hard as other children? Y N Has your child ever had a bumpy, swollen reaction to a TB skin test?

N

Y

N

In the event of a natural disaster or other situation that makes it prudent to evacuate immediately to a safe location, I agree to allow my child to be transported in whatever vehicles the Director or acting person in charge deems the best option at that time. Recognizing that an evacuation would occur only in the most extreme circumstances, I agree to hold the Center, the Director, and members of the staff harmless in the event of an accident.

Signature of parents

Y N I have received a summary of the licensing requirements. Y N I do hereby-authorize emergency medical care for my child by the staff and teachers at Northside Learning Center. N I have received and read a copy of the NLC Parent Handbook and I agree to abide by the rules and regulations therein.

N

Signature of parents

Please sign below if you give permissions for NLC to put your child's picture on our Facebook page. This page is open to the general public.

Signature

Date

Northside Learning Center Child's Application