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:

  1. I agree to give two weeks written notice before withdrawing my child.
  2. Tuition is due regardless of absence or holiday (no make-up days).
  3. Weekly tuition/Subsidized co-payments are due weekly, one week in advance.
  4. The center reserves the right to refuse services if we feel a child’s continued enrollment will pose a danger to himself or others.
  5. The center has the right to refuse services because of non-payment.
  6. I agree to submit any documentation requested by the center (physical, food program, etc)
  7. 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: ______