Baharestan Kids Student Application Form

Baharestan Kids student application form

Child First and Last Name______Gender______Birthdate:______

Father’s First and last Name ______Cellphone______E-mail______

Mother’s first and last Name ______Cell Phone ______E-mail ______

Address______Home Phone______

Amount of exposure to Persian at home (please check all that apply):

□ Mother exclusively in Persian

□ Father exclusively in Persian

□ Mother some Persian

□ Father some Persian

□ Grandparent(s)

Comments: ______

Child’s language aptitude:

How well does your child understand Persian?

□ Comprehension: None

□ Comprehension: Basic vocabulary

□ Comprehension: extensive vocabulary

How well does your child speak Persian?

□ Verbal: None

□ Verbal: Basic vocabulary

□ Verbal: fluent

Comments: ______

What program(s) are you applying for?

□ Morning Joojeh class age 2 to 5

□ Afternoon Parastoo class age 2 to 6

□Oghab Farsi classes

Preferred start date/ comments: ______

How did you hear about Baharestan kids? ______

Sample of our lunch menu:

We make healthy, kid-friendly meals using our delicious and nutritious Persian and world recipes.

All meals and snacks are homemade with only the best ingredient. They are not only appealing for kids to eat but also pack in vitamins, minerals, and other nutrients they need. A healthy, balanced diet for children provides essential vitamins, minerals and
other nutritional goodies that kids need for healthy growth and development.

Monday / Tuesday / Wednesday / Thursday / Friday
Lunch
Adas Polo w/chicken tenders and cucumber-yogurt sauce / Lunch
Mini turkey meatballs w/
smashed red potatoes / Lunch
Grain Pasta w/ tomato
Sauce cucumbers Steam zucchini / Lunch
Chicken stew w/ brown
Rice& steam broccoli / Lunch
Chess pizza
celery &guacamole
Snack
Apple Slice w/Sunflower
Butter / Snack
Multigrain Pita Chips
& guacamole / Snack
Chopped apples with bit
of cinnamon & brown
sugar / Snack
Oatmeal cookie &
Feta cheese / Snack
Melon and Berry Salad

Baharestan Kids student emergency contact

Emergency contact

First and Last Name ______Cell Phone ______E-mail ______

______

Pediatrician Name and Last Name ______Phone ______

Dentist’s Name and Last Name ______Phone ______

Medical Insurance carrier ______

Student’s Allergies ______

Does your child have any dietary restrictions? ______

Student’s Daily medication______

Does your child have any special needs we should be aware of? ______

______

Name of Persons Authorized to take child from the facility

Name and Last Name ______Relationship______

Baharestan Kids Parental/Guardian Photograph use permission

We are sending you this parental form to both inform you and to request permission for your child’s photo/image to be published on the Baharestan Kids website and Face book page.

Student’s Name: (print) ______Student’s

Parent/Guardian: (print) ______

Signature of Parent/Guardian: (sign) ______

Relation to Student: ______

Date: ______

Waiver of Liability, Release, Assumption of Risk & Indemnity Agreement

Children’s Last Name, First Name______Date of Birth ______

Parent/Legal Guardian Last Name, First Name ______

Address: City ______State ______Zip ______

Phone ______Cell______E-mail ______

Driver’s license Number & State ______

This Waiver of Liability, Release, Assumption of Risk, and Indemnity Agreement (“Agreement”) is a legally binding agreement. By signing this Agreement:

I hereby release and hold harmless Baharestan Kids, and its owner NargesAbbasiOrtakand , employees, volunteers, child care worker, and all other person or entities acting for them from any and all claims, demands, suits, cost and charges, in connection with or arising out of NargesAbbasiOrtakand home daycare ( Baharestan Kids ) service, including but not limited to, personal injury, bodily harm, injury, or property damage occurring while the above child/children is/ are in their care at NargesAbbaasiOrtakand home daycare ( Baharestan Kids); and

I hereby acknowledge that I have read, accept and understand the NargesAbbasiOrtakand (Baharestan Kids) home daycare policy.

Signature of Parent/ Legal Guardian ______

Painted Name of Parent/ Legal Guardian______