APPLICATION FORM Summer 2007
SCHOOL AGE SUMMER APPLICATION
Green Trees Early Learning Center, Inc.
102 State Route 2001 Milford, PA 18337
Phone: (570) 296-9404
Child’s Name: ______D.O.B:______
Address: ______E-Mail: ______
______Application Date: ______
Phone #: ______Allergies: ______
Mother’s Name:______Father’s Name: ______
School Age Program:
A. Half-day program 9a-1:00pm (Includes lunch, 1 snack)
Daily Weekly
$22.00 $110.00
Please indicate which mornings your child will be attending.
M______T______W ______TH ______F ______
B. Full day (10hrs) program 6:30am - 6:00 PM (Includes Breakfast, lunch, 2 snacks)
Daily Weekly
$30.00 $150.00
Please indicate which days your child will be attending.
M______T______W ______TH ______F ______
ENROLLMENT FEE (Non-refundable): An initial registration fee of $35.00 is due at time of registration for new families. A subsequent re-enrollment fee will be charged for each enrollment term (fall and summer). Non-refundablesecurity deposit is required for new enrollments. Security will be applied towards last week of tuition when appropriate notice is given.
Please note the following:
- I agree to give two weeks written notice before withdrawing my child.
- Tuition is due regardless of absence or holiday (no make-up days).
- Weekly tuition/Subsidized co-payments are due weekly, one week in advance.
- The center reserves the right to refuse services if we feel a child’s continued enrollment will pose a danger to himself or others.
- The center has the right to refuse services because of non-payment.
- I agree to submit any documentation requested by the center (physical, food program, etc)
- I understand I am required to pay a security deposit equal to one (1) week of tuition due at time of enrollment.
Parent Signature: ______DATE:______
Green Trees Early Learning Center, Inc.
102 State Rt. 2001, Milford, PA 18337
Phone: (570) 296-9404
EMERGENCY CONTACT FORM
Child’s Name: ______D.O.B:______
Address: ______Allergies:______
______Home #______
Mother’s Name: ______Home#if different______
Employer: ______Work #:______
Address: ______Cell #: ______
Father’s Name: ______Home #if different______
Employer: ______Work #: ______
Address: ______Cell #:______
Emergency contacts: (if parent cannot be reached)
NAME PHONE: (WORK/HOME/CELL)
1. ______W______H______C______
Address: ______Relationship: ______
2. ______W______H______C______
Address: ______Relationship: ______
3. ______W______H______C______
Address: ______Relationship: ______
Authorized Pick- up (other than mother or father as listed above)
May write SAA if Same As Above
NAME PHONE: (WORK/HOME/CELL)
1. ______W______H______C______
Address: ______Relationship: ______
2. ______W______H______C______
Address: ______Relationship: ______
3. ______W______H______C______
Address: ______Relationship: ______
My child may not be released to the following person (legal documentation required if person is parent/guardian):
Name: ______Relationship: _______
Parent Signature: ______Date: ______
Green Trees Early Learning Center, Inc.
102 State Rt. 2001, Milford, PA 18337
Phone: (570) 296-9404
EMERGENCY INFORMATION AND CONSENT FORM
CHILD’S NAME: ______DATE: ______
Written permission is given for: (Please check the following items in which you give permission)
_____Emergency Medical Care_____ Permission to share information with School District
_____First Aid by Staff/CPR_____ Application Sunscreen
_____Developmental/Health Screenings
_____Administration of Special Dietary or Dental Needs
_____Permission to contact Physician for Medical Information
_____Walking Trips
_____Water activities/wadingINCLUDING CREEK EXPLORATION
_____Photograph or Videotaping for publication, public relations/Press Releases, and Social Media.
_____Administration of Medication (Per physician’s instructions)
Are there any special medical or dietary information for management in an emergency situation – Allergies, Seizures or conditions including reactions and medication needs?PLEASE MARK N/A IF NOT APPLICABLE
Medical Problems: ______
Reaction Symptoms: ______
Medication Needed: ______
Has your child been vaccinated for chicken pox?YES______NO______
Has your child had the chicken pox?YES______NO______
Name and Address of Child’s Physician or Source of Medical Care:
Physician’s Name: ______Physician’s Phone#______
Address: ______
______
Insurance or Medical Assistance for your child:
Insurance Company:______
Subscriber’s Name:______
Group/Policy Number:______
Parent Signature: ______Date: ______