Norwood Park Community Learning Center Student Enrollment/information Form

CHILDS NAME

First NameLast Name

Gender and Pronouns

Age

Grade

Date of Birth

Date

Ethnicity:

Other Questions:

My child qualifies for free or reduced lunchMy child is an english language learner

PROGRAM OPTIONS:

AM (7:00-8:40) $35/Week

PM (3:38-6:00) $45/Week

BOTH AM & PM $70/week

Clubs ONLY (2 FREE-Additional form required)

Summer Program $202/week

Break Program (winter and spring if offered) $42/day

Program Choice:

AM (7:00-8:40) $35/WeekPM (3:38-6:00) $45/WeekBOTH AM & PM $70/week

Custodial & Legal Guardian is:

MotherFatherOther

Mother/Legal Information

First NameLast Name

Address

HOME ADDRESS

Street Address Line 2

CITY

STATE

ZIP

PHONE

EMPLOYER

WORK PHONE

EMPLOYER ADDRESS

EMAIL ADDRESS

example@example.com

FATHER/LEGAL GUARDIAN INFORMATION:

First NameLast Name

Address

HOME ADDRESS

Street Address Line 2

CITY

STATE

ZIP

PHONE

EMPLOYER

WORK PHONE

EMPLOYER ADDRESS

EMAIL ADDRESS

example@example.com

Emergency Contact #1

First NameLast Name

RELATIONSHIP TO CHILD

PHONE

WORK PHONE

Emergency Contact #2

First NameLast Name

RELATIONSHIP TO CHILD

PHONE

WORK PHONE

Name #1

First NameLast Name

PHONE

RELATIONSHIP TO CHILD

Name #2

First NameLast Name

PHONE

RELATIONSHIP TO CHILD

I give staff permission to use photographs, writing, artwork, TV appearances, etc. for the promotional materials, presentations and documentary purposes.

YesNo

I give staff permission to transport my child for the purpose of program activities.

YesNo

I have received and signed the program handbook.

YesNo

I give permission for CLC staff to share and receive necessary information from all CLC partners to assist with providing the best program experience for my child.

YesNo

I give permission for the CLC lead agency to arrange for emergency treatment at the nearest emergency medical facility.

YesNo

I have read the DHHS parent information Brochure for Licensed Child Care.

YesNo

I understand sunscreen and/or insect repellant will not be provided during the school year and if I want my child to use it I must supply it myself.

YesNo

By signing below I give permission for my child to participate in program activities. I understand that the CLC does not carry health and accident insurance for my child/youth, and that I as guardian will be primarily responsible in case of injury where bills are incurred. As the parent/guardian, I will work as a partner with staff to ensure my child is successful in the program. The information I have listed is correct to the best of my knowledge and I will notify the program staff of any changes to the information in a timely manner.

DATE

Date

We are committed to providing a safe and stimulating environment for your child. Our programs depend upon the talents and resources from many in our community.

Select all that interest you:

I would volunteer to assist with the daily program activitiesI would like to share my hobbies, interests and talents by leading a clubI would like to give a financial donation to support the CLC to assist low-income families' program feesMy employer and/or company may be able to help financially or with donations

My Child May Use:

MEDICAL INFORMATION/SPECIAL REQUESTS (IMPORTANT REQUIRED): List any medical conditions, allergies to food/medications, special diets or any conditions that may affect your child's health while in the program, include any medications your child is taking or please indicate NA if not applicable:

CHILDS PHYSICIAN

PHONE

I trust that Norwood Park CLC staff will use their best judgment as situations arise and if in doubt they will call for verification. I have determined that the Norwood Park CLC staff is competent to give or apply medication to my child. I understand that the Norwood Park CLC program director has the responsibility to assess the ability of the staff to give or apply medication safely.

Child's Name

First NameLast Name

Parents Signature

Date

Student Name

First NameLast Name

Parent/Guardian Name

First NameLast Name

Tuition Option:

Before School ONLY 7:00am-8:40am $35/WeekAfter School ONLY 3:38pm-6:00pm $45/WeekBefore and After $70/WeekMy child qualifies for Title XX and I have been given DHHS the Provider ID #77897697

Start Date

Date

Expected Days of Attendance:

Drop off Time:

Pick Up Time:

Tuition Acknowledgement Please initial next to each statement to indicate understanding of this tuition agreement.

I understand that payment is due prior to my child receiving care at the Northeast Family Center Brownell Community Learning Center.I understand returned checks and declined credit or debit cards will incur a fee of $25 and will not be run twice.I understand that if my child is not picked up by 6:00pm, there will be a $1 charge per child for every minute.I understand by completing the automatic bill pay option I authorize the Northeast Family Center to charge my account as directed on the form.I understand payment and/or payment arrangements must be made BEFORE my child can attend Brownell CLC.I understand that methods of payment accepted will only be: payment through My Procare account, money order, check, or cash.

ParentGuardian Signature

Date

Please select which payment option you choose:

My Procare accountDebit/Credit CardACHCash/Check/Money Order

*If you default on your payment method chosen above (fail to pay the correct amount by the required deadline), your account will be enrolled in Automatic Bill Pay and the NFC will begin charging the card on file for the amount and frequency of your program.

I understand and agree to the above stated policies

Disciplinary Policy & Procedures

- A critical incident includes any behavior that creates safety concerns for self or others, harmful and/or disruptive behaviors that impede other students, physical aggression that warrants adult staff to protect others or severe misuse of materials/tools

- One critical incident results in a one-day suspension and a phone call home discussing the behavior/return-to-care expectations, a second critical incident results in a three-day suspension with an in-person meeting to discuss behavior/return-to-care expectations, and a third critical incident results in expulsion from the program and an in-person meeting.

- Any use of racist/discriminatory language or profanity may result in disciplinary action including but not limited to suspension and or expulsion from CLC program.

- If a parent is called to come and pick up their child due to the child’s behavior, parents will need to come in and remove the child from the space and a parent conversation will be scheduled for a later time. This is to ensure the safety of everyone at CLC.

Health Exclusions:

- CLC will follow and comply to all LPS exclusion/health and safety policies

- Students may return when free of symptoms after more than 24 hours or with written statement/permission from a physician

- Students may be sent home if they have 100+ fever, undiagnosed rash/skin lesion, inflamed red eyes/drainage, frequent/persistent cough, infected/draining sores, have vomited, etc.

Mandatory Reporting:

- All CLC staff are mandated reporters are required to report any suspicion of abuse or neglect to the appropriate authorities

Parent/Guardian Code of Conduct:

- A parent/guardian must meet a staff member at the door in order to pick up your child. Parents may wait at the SEM desk for their child. Parents are not permitted to wait inside the school with the exception of meeting with a member of CLC or LPS staff.

- If your child is walking home, you MUST notify CLC staff and have a written plan with a set time that your child will walk home every afternoon.

- No parent or adult is permitted to curse or use other inappropriate language on agency property at any time, whether in the presence of a child or not.

- No parent is allowed to threaten/intimidate staff.

I understand and agree to the policies stated above:

Parent/Guardian Name

First NameLast Name

Date

Norwood Park Community Learning Center Student Enrollment/information Form

Student information

**$25 non-refundable registration fee once per year *Checks should be made payable to: Northeast Family Center.**

Family Information

EMERGENCY CONTACTS AND INFORMATION

AUTHORIZED ESCORTS OTHER THAN PARENT/GUARDIAN OR EMERGENCY CONTACTS: (N/A IF NOT APPLICABLE)

Permission Form

PARENT/GUARDIAN PARTICIPATION QUESTIONS

Norwood Park CLC Medication Form

Norwood Park CLC Tuition Agreement

Activity/Enrollment Fee $25 per family

Payment Policies and Procedures

CLC Morning & Afternoon Care will began: August 12, 2024