New Family – Summer Enrollment Application

All information will be kept confidential

Child’s Name:

LastFirstMiddle

Preferred Name: ______Birth date: ______/______/______

Age: ______years ______months Gender: (circle) Male or Female

Allergies:

(Circle) Mother - Father - Guardian

Full Name:

Home Address:

Home Telephone:

Cell Phone:

Email Address:

Occupation:

Work Phone:

(Circle) Mother Father Guardian

Full Name:

Home Address:

Home Telephone:

Cell Phone:

Email Address:

Occupation:

Work Phone:

Resides with: (Check One)

__ Mother/Father___ Mother Only ___ Father Only __ Mother/Stepfather

___ Father/Stepmother ___ Grandparent(s) ___ Guardian ___ Other

Title For Mailing: (Circle) Mr./Mrs. Mr. Mrs. Miss. Dr./Mrs. Dr./Mr. Dr.

Names and ages of other children in the family:

Do you currently attend Timberlake Church? ______Yes _____No

Are you a member? ______Yes _____ No

Please tell us how you became aware of TCP: ______

In what previous group experiences has your child been involved?

Please help us get to know your child by writing something about him/her (i.e. likes/dislikes, favorite activities, favorite foods, personality traits):

If you answer YES to any of the following questions, you may be contacted by our office staff for further information:

  1. Has your child been tested or treatedfor concerns with speech, hearing, physical, emotional or social development? No___ Yes___ (please describe)
  1. Does your child have any food allergies? No___ Yes___

If so, please list and describe any signs or symptoms of a reaction:

  1. Does your child have any allergies other than food allergies? Please describe:
  1. Does your child have any medical conditions (i.e. Asthma, diabetes, chronic illness, etc.)? No___ Yes___ (please list)
  1. Does your child take any prescription medication? No___ Yes___ (please list) ______

Does your child need to take this medication at school? No__ Yes___

If yes, you will need to fill out a medication authorization form with instructions from your child’s doctor.

  1. Has your child had any surgeries? No___ Yes___

Please list, along with any limitations since surgery

  1. Have there been any special circumstances at home (i.e. divorce, remarriage, adoption, moving, new sibling, etc.)?
  1. What kind of behavior management techniques do you frequently use with your child?
  1. What is your child’s typical schedule? Please include any regular nap times.
  1. Is your child potty trained? ______if so, can he/she use the toilet independently?

TCP EMERGENCY INFORMATION

In the event that we cannot reach either parent or guardian please list whom we may call to pick up your child. Children will not be released to individuals who are not on this list. Please contact our office immediately should this information change.

Full Name:Phone NumberRelationship to Child

1. ______

2. ______

Out of area contact (required in the case of a natural disaster):

NamePhone NumberRelationship to Child

Preferred sources of Medical Care for your child:

Physician’s Name:

Telephone:

Dentist’s Name:

Telephone:

Hospital Name:

Telephone:

Date of your child’s last pediatric physical: ______

Health Insurance Company:

Policy #:

Are there any medical problems, allergies, or special conditions that health care professionals would need to know while they are treating your child? ___Yes ___ No

If yes, please describe:

Consent for Medical Care and Treatment of Children:

I hereby give permission that my child, ______, be given emergency treatment to include First Aid and CPR by a qualified childcare staff member at Timberlake Christian Preschool. In the event that I cannot be contacted, I further authorize and consent to medical, surgical and hospital care, treatment and procedures to be performed for my child by a licensed physician or hospital when deemed necessary or advisable by the physician to safeguard my child’s health. I waive my right of informed consent to such treatment. I also give permission for my child to be transported by ambulance or aid car to an emergency center for treatment.

I declare under penalty of perjury under the laws of the State of Washington that the foregoing is true and correct:

______

SignatureDate

Please Select Summer School Attendance Options and Appropriate Tuition

Required Enrollment Fees:

Application Fee: None

Tuition Deposit: 50% of first session tuition

Extended Care:If selected on the Application will be billed two weeks prior to the start of school.

Summer Program - June 21, 2010 to August 20, 2010

Timberlake Christian Preschool is happy to provide a summer program for children ages 2.5 through 5 years. The program will be similar to our preschool program with a bit less focus on curriculum and more time for outdoor play (weather permitting).

Please Note:A slight adjustment to our operating hours during the summer months:

  1. We do not offer before-school care (7 to 9 a.m.)
  2. Hours are 9 a.m. to 6 p.m., Monday through Friday
  3. Half-Day (9 a.m. to 12 noon) or Full-Day (9 a.m. to 3 p.m.)
  4. Each session is TWO WEEKS long

Summer activities include:

4505 236th Ave. NE * Redmond, WA 98053 * Phone: 425-284-1010

  • Arts & Crafts
  • Story Time
  • Bible Lesson
  • Music & Movement
  • Show & Tell
  • Science
  • Outdoor games & sprinklers

4505 236th Ave. NE * Redmond, WA 98053 * Phone: 425-284-1010

Four 2-week sessions: (Please Circle one or More Sessions Below)

  • Session 1 - "Animal Safari":
  • June 21-25
  • June 28-July 2
  • Session 2 - "Art Exploration":
  • July 5-9
  • July 12-16

BREAK: July 19-23 (VBS is held at Timberlake this week. Preschool is CLOSED)

  • Session 3 - "Hawaii & Sea Life":
  • July 26-30
  • Aug. 2-6
  • Session 4 -"God Made Me!":
  • Aug. 9-13
  • Aug. 17-20

Schedules & Tuition Rates - Per 2-wk Session(Please Circle one or More Sessions Below)

Mon-Fri / Mon, Wed, Fri / Tues & Thurs / Diapering Fees
Full-Day / $425.00 / $342.00 / $258.00 / N/A
Half-Day – 9am-Noon / $290.00 / $175.00 / $129.00 / N/A
Half-Day – Noon – 3pm / $290.00 / $175.00 / $129.00 / N/A

After-School Care (3 - 6 p.m.) - Per 2-wk Session(Please Circle one or More Sessions Below)

2-Days Per Week / 3 Days Per Week / 5-Days Per Week
$84.00 / $126.00 / $210.00

Credit Card Authorization Form & Required Enrollment Fees

$ WAIVEDApplication Fee:($25.00 / per child)

$50% Session Tuition:(50% of first session’s tuition is due upon registration. Remaining 50%

is due two weeks prior to your child’s summer session start date.)Note: Extended Care, if selected will be billed two weeks before school starts

$Total(This amount will be billed to credit card)

First Name Last Name

Address

City State Zip

Email Phone

Credit Card Number

Expiration Date

Name on Card

Zip Code of Billing Address Amount to Charge Credit Card $

Signature

Financial Notes:

  • Tuition payment is ONLY accepted via automatic credit card billing or automatic Electronic Funds Transfer (EFT) or check. No Cash will be accepted.
  • Tuition is due in full regardless of vacations, illness or school closures.
  • A 10% sibling discount is given to families with more than one child enrolled in TCP simultaneously.
  • Extra days may be granted, space permitting, for an additional fee. Part time days may not be traded for other times or days.
  • Activity fees and other incremental fees are not included in the monthly tuition. Discounts do not apply to fees
  • Tuition is due on the 5thof each month. A late fee of $10.00 per day will be charged after the 1st of the month. Late fees are charged to your account each day payment is late. Payment for all late fees is due when you pay your tuition. All families are expected to keep their accounts current.

FINANCIAL AGREEMENT

Your child is now formally enrolled in the Timberlake Christian Preschool program. The tuition you have selected is due in advance. The registration fee and application fee and fifty percent (50%) of the first month’s tuition are non-refundable.

1. Tuition Payments:

  1. Monthly tuition is due by the 5th of the month.

B.A late fee of $25.00 will automatically be applied on the 20th of the month if tuition is not paid in full. My child may not be accepted for care until the monthly tuition plus the late fee are paid in full.

C. TCP cannot give credit for days your child is absent. As such, there is no reduction of tuition when your child misses school due to vacation or illness.

D. I understand there is a limited number of students who can attend TCP and insufficient notice may prevent TCP from enrolling another child. Therefore, after providing written notice of my intent to withdraw, I assume responsibility for one more month’s (30 days) tuition.

E.Students who enroll or withdraw in the middle of a month may pay the lesser of the daily rate or the monthly rate if the parents provide TCP with the proper written notice.

2. Late Pick Up Charges

Preschool students who do not attend afternoon extended care are ready for pick-up at 2:50 p.m. and may be picked up anytime between 2:50-3:00 p.m. A late fee of will be assessed to parents who are late picking up their child. This also applies to any parents picking a child up from after-care later than 6:00pm. Listed are the procedures the preschool will follow:

  1. The first time a parent is late a verbal warning will be given.
  1. The second time a parent is late a written warning will be given.
  1. The third time, and for any incidences after that, the parent will be charged Five Dollars ($5.00) for every five minutes he/she is late.

We understand that unavoidable or emergency situations might occur throughout the year that may cause parents to be late. Therefore, the Director will assess emergency situations on a case-by-case basis in determining late-fee assessment.

3. NSF Checks

There is a $ 25 charge for all NSF checks. In the unlikely event Timberlake Christian Preschool (TCP) must seek collection of past due fees, I agree to reimburse TCP for reasonable collection fees and interest on past due amounts. I have read the Financial Agreement and accept the conditions as stated.

Parent Signature ______Date ______

4505 236th Ave. NE * Redmond, WA 98053 * Phone: 425-284-1010