Early Childhood Learning Center

Early Childhood Learning Center

Application for Admission

Childcare Program 2016-2017 School Year

(Please return this form with your $125 Registration fee)

Childcare Hours of Operation

Monday through Friday (St. Luke Catholic School calendar)

7:00am – 4:00pm

Affiliation to the Saint Luke Community:

____ St. Luke staff member

____ Current family enrolled at St. Luke School

____ St. Luke SchoolAlumnus(a)

____ St. Luke Parishioner

____ Other (please list) ______

Please list days and times needed for childcare. ______

______

Tuition

Childcare - $50/day or $6 per hour

$125 registration fee

*Payment is expected even in the event of illness or absence.

Child’s Information

Full Name ______Gender: Boy_____ Girl ____

Date of Birth ______/ ______/ ______

Home Address ______

City______State ______Zip Code ______

Siblings? Y/N Please list names and ages ______

______

Parent Information

Mother’s Name ______Home phone ______

Cell Phone ______Work Phone ______

Employer ______

Email Address ______

Address (if different than above) ______

Father’s Name ______Home phone ______

Cell Phone ______Work Phone ______

Employer ______

Email Address ______

Address (if different than above) ______

Emergency Contact/ Authorized Person Information

The following are people you authorize your child to be released to in case of an emergency or if a parent cannot be reached. Please notify the director immediately if there is a change to this list. ONLY AUTHORIZED PERSONS WILL BE ALLOWED TO PICK UP CHILDREN.

Name ______Home phone ______

Cell Phone ______Work phone ______

Relationship to child ______

Name ______Home phone ______

Cell Phone ______Work phone ______

Relationship to child ______

Name ______Home phone ______

Cell Phone ______Work phone ______

Relationship to child ______

Medical Information

Child’s Physician ______Phone ______

Hospital Preference ______

Known Allergies ______

______

Known Medical Conditions ______

______

Medications ______

______

My child has received/receives special services (ex. Speech Therapy, First Steps): Y/ N

If yes, please describe the services and dates ______

______

*** It is required that we have an up to date record of your child’s vaccinations on file at all times. You will be expected to turn this in before your child can start school at St. Luke Catholic Church Early Childhood Learning Center and after each updated vaccine.

Consents (please initial and then sign)

______I give permission for emergency treatment to be given to my child if parents cannot be reached.

______I give permission for medication to be administered to my child by ECLC staff when brought in by a parent. Medications will not be stored at the ECLC. Medication requires written instructions for administration.

______I give permission for my child to be photographed while at school for the purpose of documentation, official school documents, and parent updates.

Parent’s Signature ______Date ______/ ______/ ______

Please submit completed application form and $125 registration fee to the St. Luke Catholic Church as soon as possible. SPACE IS LIMITED.

Laurie Breen,Director of St. Luke Catholic Church ECLC

7575 Holliday Drive East

Indianapolis, Indiana 46260

Childcare Registration & Application 2016 ECLC