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Bright Start
Application
About Bright Start
Bright Start is a free early-learning program to help prepare kids to begin kindergarten and to give them a “brighter start” into the rest of their education. We offer classes for both 3 and 4-year-olds. CLASSES BEGIN SEPT 5th. and are every Tuesday & Thursday from 9am-12:45pm. SEND QUESTIONS TO 336-829-3714. Our mission is to invest in your child both educationally and spiritually. Students will begin to learn their letters and numbers, have story-time, play-time, science lessons, arts & craft time, field trips, and more! They will hear bible stories, learn songs, and practice important social skills that will benefit them in a public school setting. We’re excited to have your child with us for the next school year!
REQUIREMENTS - check each box to show you have read and understand the requirements for Bright Start (If you are enrolling more than one student, please fill out another form for your other child)
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Each child must be completely toilet trained prior to the start of the school year.
If your child has had a fever within 24 hours, he/she may not attend Bright Start until fully recovered for 24+ hours
I understand my child must be 3 or 4 years old to be eligible for Bright Start
Today's Date
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Month
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Day
Year
Child's Name
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First Name
Last Name
Date of Birth
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Month
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Day
Year
Current Age of child
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Is the student above a new or returning student?
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New Student
Returning (my student attended Bright Start last year)
Address
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Will your child need transportation to and from Bright Start? (Please note - transportation is only available for specific areas in the city.)
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Yes
No
Which bus stop location will your child be picked up from?
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Piedmont Circle
Rolling Hills
Skyline Village Apartments
Colony Place Apartments
Cleveland Homes
Hutton St. Apartments
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Parent/Guardian Information
1st Parent/Guardian Name:
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Parent/Guardian Phone Number
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Parent/Guardians Email
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2nd Parent/Guardian Name:
Parent/Guardian Phone Number
Parent/Guardians Email
Emergency Contact:
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Relationship:
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Phone Number:
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Please enter a valid phone number.
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Safety and Medical Information
Name and Phone number of person(s) other than parents allowed to pick up your child:
List names of any specific persons who are NOT authorized to pick up your child:
Add any special instructions, such as custody or restraining orders must be added to this application and discussed. Please list any other information you'd like to include about your child:
Child's Pediatrician's Name
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Date of Last Physical
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Month
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Day
Year
Date of Last Tetanus Shot
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Month
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Day
Year
Medical Conditions:
List all current medications regardless of whether it needs to be taken at Bright Start or not:
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Insurance Information
Member's Name:
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Health Care Provider:
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Insurance Provider's Phone Number
Member ID #
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Group #
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Will your child need to take any prescription medications while at Bright Start?
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Yes
No
Allergies: (Food, Medication, Insect, or Other)
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Does your child have an Epi-pen? If yes, your child must provide Bright Start Early Learning with an Epi-pen to be kept at Bright Start during your child's enrollment. Epi-pen must be accompanied with a current prescription and a doctor's note.
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Yes
No
Please describe any specific activities to be restricted for any health reasons:
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Authorization and Signature
Read all paragraphs carefully sign your name after each one.
Child's Name:
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Today's Date
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Month
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Day
Year
Date
I give Bright Start permission to photograph and/or videotape my child for public relations and/or marketing purposes. Photos will remain archived at Bright Start and can be used for promotional purposes without notification.
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I give permission to City Lights Ministry and its staff to pick up and drop off my child(ren) to and from Bright Start Early Learning. I will waive all liability and will not hold City Lights Ministry, its staff, or volunteers responsible for any accidents resulting from transportation or any activity at Bright Start Early Learning or City Lights Ministry
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I give permission for Bright Start to transport my child off property for the purpose of field trips and/or medical care. I understand that a schedule of events will be available to me and that all events are subject to change due to weather and/or scheduling conflicts without notice.
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I authorize Bright Start management to act as the agent of the parents in any emergency situation or to administer basic first aid for the health and welfare of the child involved. I am responsible for the expenses involved if the services of a physician or hospital are required. Please request a waiver for persons requesting exemption from medical treatment.
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In the event of a medical emergency, please list preferred hospital
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By signing below I agree to adhere to all the Policies and Procedures set for by City Lights Ministry’s Bright Start Early Learning Program.
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SUBMIT APPLICATION
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