Learners Club

2011 – 2012 Student Application

2011 – 2012 Learners Club Student Application

List of Documents

Page

/ Submitted / Document
1.  / Cover
2. / List of Documents in Student Application
3. / Parents Right to Know Notice
4. / Parent/Guardian Letter
5. / Registration Form
6., 7., 8 / Child Information
9., 10 / Additional Child Information
11. / Special Needs Statement
12. / Family Information
13. / Client Characteristic Form
14. / Child Health Appraisal
15. / Authorization for Emergency Medical Treatment
16. / Walker Waiver Form
17. / Trip Consent
18. / Information Release
19. / Photo Release
20. / Internet Use – Parent/Guardian Approval
21. / Internet Acceptable Use Policy
22., 23 / Payment Agreement
24. / Fee Schedule
25., 26., 27 / 2011 – 2012 Calendar
28., 29 / Parent Reminders
30. / YDD Membership Form

BOLD ITALICS = Form Requires Parent/Guardian Signature

For Learners Club use only: Coupon redeemed? YES NO

PARENTS RIGHT TO KNOW NOTICE

Under the Delaware Code you are entitled to inspect, at any time, the active record and complaint files of any licensed child care facility.

To review a child care facility record contact:

Ellen Linen, Adm. Support Specialist I

Office of Child Care Licensing

1825 Faulkland Road

Wilmington, DE 19805

302-892-5800

OR

Dawn Clarke, Adm. Support Specialist I

Office of Child Care Licensing

821 Silver Lake Boulevard

Suite 102

Dover, DE 19904

302-739-5487

I acknowledge that I received a Parents Right to Know Notice as part of the student application from West End Neighborhood House.

Parent/Guardian name: ______

Date: ______


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Learners Club

Registration Form

This entire application must be submitted with the following:

1. $20.00 non-refundable registration fee (waived if you have Purchase of Care)

2. Proof of income (Include at least one of the following)

a) 2 consecutive pay stubs dated within the past 30 days

b) W-2 or 1040 tax form

c) Form 618D (Purchase of Care)

Please note: If you are using the Child Health Appraisal form in the application, you must include shot records.

I understand that:

·  West End Neighborhood House serves customers on a first-come, first-served

basis.

·  a place will be reserved for my child when an opening becomes available.

·  the registration fee must be paid if I do not have Purchase of Care.

·  all forms in the student application must be completed and submitted.

·  if my child is new to Learners Club, I must schedule an appointment for an

orientation with Melissa Morris.

Your child can not participate in Learners Club until you have:

·  met with his/her teacher.

·  submitted all required forms.

·  paid the registration fee, if applicable.

·  paid all outstanding West End Neighborhood House balances (including camp).

·  received official notification of his/her acceptance into the program.

Child name:
School:
Bus number:
Age: / Grade:
Parent/Guardian signature: / Date:
Learners Club Use Only:
Admission Date
/
Pending Action Discharge Date Date

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Learners Club

Child Information

Please print clearly and complete all requested information.

Child name (Last, first, middle initial): / Birthdate (mm/dd/yy):
Days child is scheduled to attend:
Hours child is scheduled to attend:
Parent/Guardian name(s):
Home address: / City, state, zip:
Home phone number: / Cell phone number (+ area code):
Email address:
Employer 1 (Business name): / Parent/Guardian working at Employer 1:
Address: / City, state, zip:
Hours of employment: / Business phone number (+ area code):
Employer 2 (Business name): / Parent/Guardian working at Employer 2:
Address: / City, state, zip:
Hours of employment: / Business phone number (+ area code):

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Learners Club

Child Information (continued)

Person (other than parent) to be notified in an emergency if the parent is unavailable
Name: / Relationship to child:
Address: / City, state, zip:
Home phone number (+ area code): / Cell phone number (+ area code): / Work phone number (+area code):
Persons (other than parent) to whom child may be released. Persons must be 18 or older.

1.

Name: / Relationship to child:
Home phone number (+ area code): / Cell phone number (+ area code):

2.

Name: / Relationship to child:
Home phone number (+ area code): / Cell phone number (+ area code):

3.

Name: / Relationship to child:
Home phone number (+ area code): / Cell phone number (+ area code):

4.

Name: / Relationship to child:
Home phone number (+ area Code): / Cell phone number (+area code):

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Learners Club

Child Information (continued)

Emergency Medical Care

I, , the parent (or legal guardian)

of , who is my minor child, hereby authorize emergency medical treatment for my child in the event I cannot be contacted to give permission to treat. I understand I will be financially responsible for the cost of such treatment.

Transportation

I, , the parent (or legal guardian)

of , who is my minor child, hereby give permission for my child to be transported with his/her caregiver.

Parent/Guardian signature / Date
Medical Information
Name of child’s physician:
Address: / City, state, zip:
Phone number (+ area code):
/ Office hours:
Health insurance identification information:
Special medical information (allergies, etc.):

The above information is essential for your child’s protection. Be sure to keep the information current.

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Learners Club

Additional Child Information

Child name:
Age:

We are requesting the following information in order to help us better understand, and therefore better care for, your child. Please help by answering these questions as completely and clearly as possible. This information is confidential and will remain only with us. Thank you for your cooperation.

1. / Has your child been in group care before? Yes No
2. / If you answered “yes”, was this care provided in:
Family child care home / Early Care and Education Center / School-Age Center / Other
3. / How did your child respond to that arrangement?
4. / How do you think your child will respond to this arrangement?
5. / Why are you seeking to change your provider?
6. / Does your child take any medication? Yes No
7. / If you answered “yes”, note the reason(s):
8. / What are your child’s favorite and least favorite foods?
Favorite: / Least:
9. / What are your child’s hobbies and interests?
10. / What is your child’s favorite subject(s) in school?
11. / What subject(s) does your child find difficult?

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Learners Club

Additional Child Information (continued)

Please check any that apply.

If your child has been identified as having a disability or special need, please provide us with copies of his/her:

IEP Developmental and educational goals progress reports

IFSP Assessments and referrals to support services

Section 504 Plan

In the space below, please provide details about any items that you checked.

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Learners Club

Special Needs Statement

In order to ensure the proper care for your child, we are requesting the following information. It will remain confidential and will be shared only with staff. If this information changes at any time, please inform us so that we can make the proper changes to this document.

Child name: Date:

Please list your child’s medical, developmental, and educational needs.

Please list your child’s previous serious illnesses or injuries, as well as any existing illnesses or injuries.

Please list all your child’s prescribed medications (including those for emergency situations), as well as the reasons for their use.

Please list all your child’s allergies, including food allergies. Specify their severity and provide any special instructions.

If you need additional space, please use the back of this page.

WEST END NEIGHBORHOOD HOUSE

Learners Club

Family Information

Names of all Household Members

/

Age

/

Gender

1.
2.
3.
4.
5.
6.
7.
8.

Please check any that apply.

Custodial parent Non-custodial parent

Joint custody Legal guardian

Is there a court order provided for custody and visitation arrangements? Yes No

If yes, you must provide documentation.

Have members of your child’s family and/or household experienced?

Chronic/terminal illness Handicapping condition

Depression Child abuse/neglect

Drug/alcohol addiction Suicide

Teen pregnancy SIDS (Sudden Infant Death Syndrome)

Other:

Have members of your child’s family and/or household experienced?

Separation/divorce Move to a new home

Death of a family member Enrollment in a new school

Death of a pet Birth of a sibling

New job Incarceration

Unemployment Addition of a new person to household

Other:
Comments:

Individual Client Characteristic Form

Participant Name:

Ethnicity/Race (please check only one):
African American
Asian
Hispanic/Latino
Native American
Native Hawaiian/Pacific Islander
White
Other
Multi-Race (2 or more) / Does participant have health insurance?
Yes No
Is the participant differently-abled and/or physically challenged?
Yes No
Family Type (please check only one):
Single parent – Female
Single parent – Male
Two parent household
Other / How many sources of income does family have?
Zero income More than one source
Please check all sources of income:
Employment Only
Employment
+ Other Sources
General Assistance / Pension
Social Security
SSI
TANF
Unemployment Insurance
Family Size / Gross Yearly Income (Please Check Family Size and Corresponding Income)
Up to 50% / 51% to 75% / 76% to 100% / 101% to 125% / 126% to 150% / 151% to 175% / 176% to 200% / 201% and Over
2 / Up to $7,285 / $7,286 - $10,928 / $10,929 - $14,570 / $14,571 - $18,213 / $18,214 - $21,855 / $21,856 - $25,498 / $25,499 - $29,140 / $29,141 and Over
3 / Up to $9,155 / $9,156 - $13,733 / $13,734 - $18,310 / $18,311 - $22,888 / $22,889 - $27,465 / $27,466 - $32,043 / $32,044 - $36,620 / $36,621 and Over
4 / Up to $11,025 / $11,026 - $16,538 / $16,539 - $22,050 / $22,051 - $27,563 / $27,564 - $33,075 / $33,076 - $38,588 / $38,589 - $44,100 / $44,101 and Over
5 / Up to $12,895 / $12,896 - $19,343 / $19,344 - $25,790 / $25,791 - $32,238 / $32,239 - $38,685 / $38,686 - $45,133 / $45,134 - $51,580 / $51,581 and Over
6 / Up to $14,765 / $14,766 - $22,148 / $22,149 - $29,530 / $29,531 - $36,913 / $36,914 - $44,295 / $44,296 - $51,678 / $51,679 - $59,060 / $59,061 and Over
7 / Up to $16,635 / $16,636 - $24,953 / $24,954 - $33,270 / $33,271 - $41,588 / $41,589 - $49,905 / $49,906 - $58,223 / $58,224 - $66,540 / $66,541 and Over
8 or more / Up to $18,505 / $18,506 - $27,758 / $27,759 - $37,010 / $37,011 - $46,263 / $46,264 - $55,515 / $55,516 - $64,768 / $64,769 - $74,020 / $74,021 and Over
Family’s current housing situation:
Own Home Rent Homeless Other



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Learners Club

Parent/Guardian Authorization for Emergency Medical Treatment

Child Name:

Parent/Guardian Name:

My child’s health appraisal is correct, to the best of my knowledge, and the person herein described has permission to engage in all prescribed program activities, except as noted by me and the examining physician.

In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by Learners Club to hospitalize and admit, secure proper treatment for, and to order injection, anesthesia or surgery for my child, as named above.

Parent/Guardian Signature: ______Date:

WEST END NEIGHBORHOOD HOUSE

Learners Club

Walker Waiver

I hereby give permission for my child to walk to West End Neighborhood House from

his/her bus stop after school. I understand that s/he must walk directly to West End,

enter through the main doors, and immediately go into the Learners Club classroom.

Upon entering the classroom, s/he should see a teacher in order to be signed in. I

understand that once a teacher signs in my child, s/he is then under the care and

supervision of Learners Club.

West End Neighborhood House, United Way, and its agents are neither liable nor

responsible for my child when s/he is en route to Learners Club.

Child name
Parent/Guardian name
Parent/Guardian signature
Date

WEST END NEIGHBORHOOD HOUSE

Learners Club

Trip Consent

I hereby give permission for my child to participate in physical activities, play in the

local parks, take walks in the neighborhood, and participate in any field trips off West

End Neighborhood House premises. West End Neighborhood House, United Way, and

its agents are held harmless for any injury(ies) arising from participation in the

programs of said agencies and the actions of the agents of said agencies.

Child name
Parent/Guardian name
Parent/Guardian signature
Date

WEST END NEIGHBORHOOD HOUSE

Learners Club

Information Release Form

Please complete and sign this form. Learners Club staff will place a copy of this form in your child’s file. The original will be sent to

for its records.

(Child’s school)

Permission is hereby granted to the appropriate office and staff of the above named school to release information (report cards, test scores, grades, behavioral reports, etc.) on

Child name

to Learners Club staff. Permission is also granted to Learners Club staff to contact my child’s principal, guidance counselor, teachers, and other above named school officials, as well as to release information (attendance, progress reports, behavioral reports, etc.) to them.

Furthermore, permission is granted to Learners Club staff to obtain my child’s report card from my child, copy it, and return it to him/her.

Parent/Guardian name

Parent/Guardian signature

Date

WEST END NEIGHBORHOOD HOUSE

Learners Club

Photo Release Form

Dear Parent or Guardian:

West End Neighborhood House often takes pictures and/or videos of youth enrolled in our programs. We are asking your permission to use these pictures/videos of your child/ren in our brochures or other promotional materials. Please read the following release carefully and sign in the space provided.

Release Form

I hereby give my permission for West End Neighborhood House, their assigns, licenses and legal representatives the irrevocable right to use and reuse copyright and renew copyright of my child/ren’s picture, portrait, photograph, or video in all forms and media and in all manners, including composite or distorted representations for advertising, trade or other purposes, and I waive any right to inspect or approve the finished product, including written copy that may be created in connection therewith.