12/4/2018

APPLICATION FOR CHILD CARE SERVICES

Weekday Ministries

3319 W. Liberty Ave.

Pittsburgh, PA15216

412-531-5790 Fax: 412-531-7155

Mettelise Ziegler, Director

Name of Child______Birthdate______Male/Female______

Address______State______Zip______

Parent/Legal Guardian #1______Relationship______

Address______

Work Address______

Telephone______cell ( ) home ( ) work ( )

Email______

Parent/Legal Guardian #2______Relationship______

Address______

Work Address______

Telephone______cell ( ) home ( ) work ( )

Email______

Previous day care experience?______Where?______

Who will be paying for our services?______

If you are also applying for the PreK program, fill out the section below.

______PreK 3 (3 years old by 10/1 and toilet-trained) Meets T Th 9-11:30am (Sept. – May)

______PreK 4 (4 years old by 10/1) Meets M W F 9-11:30am (Sept. – May)

______Transition (T) Class (5 years old by 12/31) Meets 12:30-3:00PM M-F (Sept. – May)

(Please complete the reverse side)

We do not exclude children with special needs if we can provide a safe environment. If there are special needs, please let us know and provide an IEP (Individualized Education Plan).

Special needs ______

IEP will be coming from (agency and contact name)______

Do you have a home church?______(Church Name)

Would you like information about Mt.LebanonUnitedMethodistChurch?______

Requested Start Date______

Days/Hours when day care is needed______

Registration Fees(Choose one)

  • $100 nonrefundable fee for registrations held less than 30 days ______
  • $100 plus 50% of the first month’s tuition for registrations held longer than 30 days. The 50% charge will be credited to the first month attended. This fee will only be refunded if the registration is cancelled 60 days or more before the start date.______
  • IMPORTANT: If your child does not begin on the start date, an additional 50% of the monthly tuition must be paid to hold the spot one additional month. This extra fee will not be credited to the first month’s tuition. After the one additional month, the reservation will be cancelled with no refund. Your signature below indicates your acceptance of this agreement.

Signature of Parent or Guardian______Date______

Non-discrimination policy:

Admissions, the provisions of services, and referrals of clients shall be made without regard to race, color, religious creed, disability, ancestry, national origin (including limited English proficiency), age or sex.

Program services shall be made accessible to eligible persons with disabilities through the most practical and economically feasible methods available. These methods include, but are not limited to, equipment redesign, the provision of aides, and the use of alternative service delivery locations. Structural modifications shall be considered only as a last resort among available methods.

+ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +

This section is for center use.

Date enrolled (start date ) ______Date deposit received______Amount______check #______

Group/Room ______Director’s Signature______

PreK program ______