Registration Form - Friedens Early Learning Academy (FELA) 2014-15
2555 Friedens Church Road, Seguin Texas 78155. 830-303-7729. www.friedensearlylearningacademy.org
CHILD’S NAME: __________________________ BIRTHDATE: _________________
Home Address: ________________________ City/Zip:_________________________
Home Phone: ____________________________ Admission Date:_________________
E-Mail Address:______________________________________ Work email_____________________
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MOTHER/GUARDIAN Name: Employer: Work Phone: Cell: Driver’s License #:
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FATHER/GUARDIAN Name: Employer: Work Phone: Cell: Driver’s License #: |
One contact, other than the parents, is required for registration. If the parents are unavailable, the following individual has permission to transport and seek care for this child.
Name Drivers License# Address Phone (work/home/cell)
_________________________________________________________________________________________________
The following people are only authorized to pick up this child.
Name/Address Driver’s License# Phone (work/home/cell)
_______________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
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My child is normally in care on the following days and times:
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Mondays from: to:
Wednesdays from: to:
Emergency Medical Release: In the event that I cannot be reached or cannot make arrangements for emergency medical attention at the time of illness or accident I hereby authorize this facility to transport my child to the closest medical facility and authorize the medical providers to provide necessary treatment.
Doctor Address ______________________________________ Phone ______________
Parent/Guardian Signature
ALLERGIES: Child is known to have allergic reactions to:
Allergen Reaction Best way for FELA to handle
__________________
__________________
__________________
Parent/Guardian Signature________________________ Date ________________
General Health Information
Child’s Name: ___________________________________
MEDICAL CONDITIONS: Describe any medical conditions that your child may have, and how you would like our staff to respond. Please include any past serious illnesses or injuries, disabilities, and hospitalizations that have occurred in the past 12 months.
Medical Condition Best way for FELA to handle
_________________________________________________________________________________________________
_____________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
MEDICATIONS: Please list any medication prescribed for long-term, continuous use
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Medication Authorization
Should my child require medication brought from home, I authorize FELA staff to administer this medication to my child. I understand that I must fill out and sign a medication form that is kept in the FELA office. I understand that all medication must be in the original container and labeled appropriately. This includes first and last name of child and amount to be given. I understand that I am responsible for providing a measuring device to administer the medication.
Parent/Guardian Signature ____________________________
Well Check
I understand that a requirement for participation in this program is a doctor’s examination every 12 months. I understand that I must present a statement each year from my child’s doctor within one week of admission to verify that he or she is physically able to participate in the day care program.
Parent/Guardian Signature______________________________
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Full Day |
18 mo.-2 yrs. |
3-4yrs. |
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5 days a week |
505.00 |
490.00 |
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Mon., Wed., Fri. |
325.00 |
315.00 |
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Tue., Thu. |
225.00 |
215.00 |
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Half Day |
18 mo.-2 yrs. |
3-4 yrs. |
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5 days a week |
275.00 |
265..00 |
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Mon., Wed., Fri. |
170.00 |
165.00 |
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Tue., Thu. |
120.00 |
115.00 |
Preschool Drop-off
5 days a week 330.00
FAST
5 days a week 175.00
Drop-In Rate Full Day--$40 Half Day--$25 (for registered students only)
10% discount for second, third child
Photo Release
I________________________________give permission for my child, _______________________’s
Photograph to be used in advertising projects such as brochures, postcards, and online sites such as
the churches webpage and Facebook.
_____________________________________________________date_______________________
