Little Lights Application for Twos and Threes Program

Little Lights Application for Twos and Threes Program

Turn in the completed form to Leigh Borge at Saint Pauls United Church of Christ, 2335 N Orchard St. Chicago IL 60614

Child’s Name ______
Address/City/Zip______Birthdate _____/_____/_____ Sex M _____ F _____
Parent’s Name ______
Home Phone ______Cell ______Work______Parent’s Name ______
Home Phone ______Cell ______Work______Preferred Email Addresses ______

Is your family a member of St. Paul’s Church? ( )Y Year joined ______( )N

Nanny/Sitter’s Name and Number (if nanny or sitter will be picking up or dropping off child) ______

Emergency Contact - other than parent

Name/Relationship/Phone Number

1. ______

2. ______

Does your child have any FOOD allergies, other allergies or medical conditions?

YES ______NO______

If YES, please provide specific details:

______

Emergency Care and Release of Liability

In case of emergency, the Little Lights staff is hereby authorized to deliver first aid and/or

to call for emergency medical assistance for my child.

I hereby release, indemnify and hold harmless, Saint Pauls United Church of Christ, its agents and employees for any claims including medical and dental.

Parent Signature: ______

Date: ______

Sessions

Session 1begins September 2017 and endsDecember 2017.
(No classes the week of Thanksgiving.)

Session 2 begins January 2018 and endsJune 2018.
(No classes during Holy Week and CPS spring break.)

Session 1 is open to children who will be 2 by September 1, 2017.

Session 2 is open to children who will be 2 by January 1, 2018.

Please check the program(s) you are applying for.

☐ Session 1 ☐ Session 2

Tuition Agreement

Session 1 Tuition for Pledging Church Members is $1,100 Session 1 Tuition for Non Church Members is $1,300

Session 2 Tuition for Pledging Church Members is $1,300 Session 2 Tuition for Non Church Members is $1,500

I, the parent/guardian of ______, hereby enter into this agreement with Saint Pauls UCC for the enrollment and education of my child in the Little Lights Twos program. If placement is secured, I will pay the tuition by the date indicated below.

ALL TUITION PAYMENTS ARE NON-REFUNDABLE AND NON-TRANSFERABLE.

Full tuition is due by September 1, 2017 for Session 1. Full tuition is due by January 1, 2018 for Session 2.

A non-refundable deposit of $100 is due upon acceptance. The deposit will be applied towards your tuition costs.

Parent Signature: ______

Date: ______

Tuition assistance is available for church members. If you would like to request assistance please contact Leigh Borge at .

Questions

Why are you interested in a program for your two or three year old? What are your goals for the program?

What is your child interested in? What are his or her favorite things to do? Help us get to know your son or daughter a little better.

Have you begun potty training? If yes, how is it going?

Does your child primarily speak any language other than English?