Name in English (As in Official Documents)

Application Form

201_ / 201_

FOR OFFICE USE ONLY
Application #: ______Admission Date: ______
Date Received: ______Class: ______

If you wish to register your child, kindly complete all the required documents and submit them to the ECC with a -one time- nonrefundable registration feeof $55.

CHILD INFORMATION

Name in English (as in official documents):

______

(First) (Father) (Family)

Name in Arabic (as in official documents):

______

(إسم العائلة) إسم الأب)) (الإسم الأول)

Gender: Male ?Female ?

Date of Birth: ______

(Day) (Month) (Year)

Place of Birth: ______

(City) (Country)

Nationality(ies): ______

Home Phone(s): ______

Home Address: ______

(Street) (Building) (Floor)

______

(City)

FAMILY INFORMATION

Father’s Full Name: ______

Name of Employer: ______

Address: ______

Business Phone: ______Cell Phone: ______

Email Address: ______

Mother’s Full Name: ______

Name of Employer: ______

Address: ______

Business Phone: ______Cell Phone: ______

Email Address: ______

EMERGENCY CONTACT

In case of an emergency, please specify the authorized people to be contacted:

Full Name / Relationship to the Child / Cell Phone
1
2
3
4
5

RELEASE INFORMATION

Please provide the following information about the people who are authorized to pick up your child from the ECC:

Full Name / Relationship to the Child / Cell Phone
1
2
3
4
5

I, the undersigned,hereby certify that all information provided above is correct and understand that all documents submitted become the property of the ECC.

Parent’s Name:______Parent’s Signature: ______

Date: ______

ATTACHMENTS

Please make sure to attach the following when submitting the application to the ECC:

One recent passport-size photo (taken within the past six months)
A clear photocopy of the child’s identity card or passport
A Family record (اخراج قيد عائلي)

Medical Record Form

201_ / 201_

*Must be returned on your child’s first day at the ECC*

CHILD INFORMATION

Name: ______

(First) (Father) (Family)

Gender: Male ?Female ? Blood Type: ______

Date of Birth: ______

(Day) (Month) (Year)

Home Phone(s): ______

HEALTH HISTORY

Please check if the child has or may have had any of the following:

__ Abnormal bleeding / bruising __ Dislocation (shoulder, etc.) __ Scarlet Fever

__ Anemia __ Ear Problems __ Seizures

__ Asthma __ Eye or Vision Problems __ Speech Problems

__ Chicken Pox __ Hepatitis __ Tonsillitis

__ Convulsions __ Measles __ Tuberculosis

__ Diabetes __ Mumps __ Other

__ Diphtheria __ Pneumonia

If any of the above is checked, please explain:

______

Did the child have any previous operation and/or severe injury? If yes, please explain:

______

SIGNIFICANT PROBLEMS

Does the child have any medical condition about which the ECC should be informed? If yes, please explain:

______

Is the child taking any medication? If yes, please list: ______

Please list any drug / food / beverage that the child is allergic to: ______

Does the child have a physical disability? If yes, please describe it in details:

______

Does the child have any special medical problem requiring limitations on his/her physical activity? If yes, please describe it in details:

______

IMMUNIZATIONS

Please indicate the last date of vaccination for the following:

Required by the Ministry of Public Health in Lebanon
Hepatitis B
Polio, Diphtheria, Pertusis, TetanosHemophilus
Measles, Mumps, Rubella (MMR)
Tuberculin test (PPD)
Recommended
Rota Virus
Pneumococcus
Meningococcus
Hepatitis A
Chickenpox / Varicella
Optional
BCG (Tuberculosis) – Optional
Typhoid – Optional

Physician’s Name: ______Physician’s Signature: ______

Physician’s Number(s): ______

Date: ______

Medical Consent Form
In the event that my child, ______becomes ill or sustains an injury while attending the ECC, I give permission to the ECC nurse to administer First Aid. I consent to a medical diagnosis and treatment, as well as any medications necessary while under the care of the nurse. I do understand that this form will apply to all future emergency situations and a copy of this form is as valid as the original. This consent form will remain in effect throughout the academic year.
Parent’s Name: ______Parent’s Signature: ______
Date: ______

Emergency Medical Consent Form

*This paper provides parent’s approval for any medical emergency given by the ECC to the child.

I authorize the early childhood center (ECC) to render emergency medical treatment for my child

when I cannot be reached or if a delay in approving this emergency action could harm him/her.

I do not authorize the early childhood center (ECC) to render emergency medical treatment for my

child when I cannot be reached or if a delay in approving this emergency action could harm him/her.

Please sign and return to the ECC.

*Name of the child:

*My name : / *Relationship to the child:
*My insurance provider: / *My child ‘s medical record number:
*Preferable (nearest)hospital where my
child would be treated in: / *My child is currently taking the following medicines:
*My child has the following allergies:
*Signature: / *Date:

Background Information Form

201_ / 201_

Please complete the form and return it signed. Information provided by parents will remain confidential.

PERSONAL DATA

Child’s Name in English (as in official documents):

______

(First) (Father) (Family)

Number of siblings at home: ______Position of the child in the family: ______

Sibling’s Name / Age / Daycare / School Attending
(If Applicable)
1
2
3
4
5

Parents are: ? Living Together (with the child) ? Divorced / Separated (child living with ______)

Child Custody Information (If Applicable):

Name of parent or guardian who has legal custody of the child: ______

Name(s) of parent(s) or guardian(s) who is/are allowed to pick up the child from the ECC:

______

Custody / access restrictions (if applicable): ______

*If there is a Custody Order or any other Order in place that pertains to the custody and/or access of the child, a certified copy of the Order(s) is to be attached to this form.*

PREVIOUS CHILDCARE EXPERIENCE

Has your child been enrolled in any childcare previously? If yes, please specify for how long.

______

Please describe your child’s previous childcare experience (if applicable):

______

LANGUAGES / ACTIVITIES

Language(s) spoken at home: ______

Other language(s) that the child is exposed to: ______

Please list some activities that you do with your child (at home and outside):

______

How often do you read to your child?

______

What are some toys and games that the child seems to be interested in?

______

HEALTH INFORMATION

Name of Child’s Physician: ______

Work Phone: ______Cell Phone: ______

Child’s Medical History:

Type of Birth: ?Normal ? Premature ? Specific Complications ______

Does the child have any medical condition about which the ECC should be informed?

______

Child’s Allergies / Food Intolerance:

Please list your child’s allergies and/or food intolerance problems:

______

SLEEPING, EATING AND TOILETING HABITS

When does your child go to bed? ______When does your child wake up? ______

Does your child have any sleeping disturbances? ?Yes ? No

If yes, please explain:

______

Does your child feed himself/herself? ?Yes ? No

Do you have any specific concern regarding your child’s eating habits? ?Yes ? No

If yes, please explain:

______

Is your child toilet trained? ?Yes ? No ? In the process

BEHAVIOR

Does your child show any aggressive behavior (kicking, biting, hitting, yelling, etc.)? ?Yes ? No

If yes, please specify:

______

Please explain what disciplinary measures you use with your child to deal with that:

______

Does your child show any particular behavior which requires special attention at school (fear, jealousy, whining, speech difficulty, etc.)? ?Yes ? No

If yes, please explain:

______

Does your child have temper tantrums? ?Yes ? No

If yes, please specify how often and how you deal with that:

______

What reward techniques (if any) do you use with your child at home to reinforce a positive behavior?

______

What makes your child angry, sad and/or anxious? What makes your child happy? Please give some specific details:

______

GENERAL INFORMATION

Please indicate any other information you would like to share about your child/family:

______

I, the undersigned, hereby certify that all information provided above is correct and understand that all documents submitted become the property of the ECC.

I also agree to inform the ECC if there are any changes in the family relationship, including any changes tothe custody/access of my child.

Parent’s Name:______Parent’s Signature: ______

Date: ______

Photography Consent Form

*As part of the documentation process of children’s work, the ECC teacher’s take photographs and videos of children in action as they participates in completing projects in the classrooms. We would like to indicate below what uses of images of your child you are willing to consent to .

We will only use the photographs in ways you agree to. In any use of these images, names and other personal information will NOT be identifies at all.

Images of my child may be used on ECC’s bulletin boards, classroom displays and Life Cubby.

Images of my child may be used as part of the LAU and ECC’s pamphlets, brochures and information booklets.

Images of my child may be used on the LAU and ECC‘s website and social media accounts.

Please do not use any images of my child in any way

Please sign and return to the ECC.

*Name of the child:

*Name: / *Relationship to the child:
*Signature: / *Date: