The J Center for Early Learning

Step 1: Parent Information

Parent 1

First Name:*

Last Name:*

Address:*

City:*

State:*

Zip:*

Employer:*

Cell Phone:*

Alternate Phone:*

Email:* (this will be used for registration confirmation)

Parent 2

First Name:

Last Name:

Check this box to copy address from above.

Address:

City:

State:

Zip:

Employer:

Cell Phone:

Alternate Phone:

Email:

Step 2: Child's Information

Child's Full Name:*

Nickname:

Date of Birth:*

Gender:*

Child lives with:

Any known special needs:*

Allergies:*

Any other health concerns:*

Please describe your child's personality and anything you think would be helpful for your teacher to know:*

Select Class: I would like to register my child for: (please select one)

CLASS	HOURS	DAYS	MONTHLY TUITION
Kindergarten	8:30am - 2:30pm	M-F	$560
Pre-Kindergarten	8:30am - 2:30pm	M-F	$460
3 Year-Old Class	8:30am - 2:30pm	M-F	$455
2 Year-Old Class	8:30am - 12:00pm	M-F	$390
12-24 Month Class	8:30am - 12:00pm	M-F	$400

Before and After School Options (paid monthly)

None
Early Einsteins (paid monthly)
All grades:	7:00 – 8:30 am	$105
All grades:	7:30 – 8:30 am	$80
Afternoon Adventurers (paid monthly)
3-year-olds to Kindergarten:	2:30 - 6:00 pm	$245
12 months to 2-year-olds:	12:00 - 2:30 pm	$200
12 months to 2-year-olds:	12:00 - 6:00 pm	$360
All-Day Learn and Play (paid monthly)
12 months to 2-year-olds:	7:00 - 8:30 am & 12 - 6:00 pm	$395
3-year-olds to Kindergarten:	7:00 - 8:30 am & 2:30 - 6:00 pm	$300

Additonal Child - Yes?

Other children in family

Name:

Age:

School:

Name:

Age:

School:

Name:

Age:

School:

Are any other languages spoken at home?*

Do you identify with a Jewish denomination (i.e. Reform, Conservative, Orthodox)? If so, which?*

If you are new to The J, please let us know how you found out about us:*

Authorized Pick-up Information:

Name:*

Relationship:*

Cell Phone:*

Name:

Relationship:

Cell Phone:

Name:

Relationship:

Cell Phone:

Medical & Other Information:

Child(ren)'s pediatrician: (name, address, phone number)*

Child(ren)'s dentist: (name, address, phone number)*

In case of emergency, transport my child to:

Hospital:*

Hospital address:*

Hospital phone:*

In case of an emergency in which the parents cannot be reached, please call:

Name:*

Relationship:*

Phone number:*

Comments, or are there any special issues in your child/ren's history of which we should be aware
(social, emotional, medical, physical, etc)?

Signature:

By submitting this enrollment application, I hereby agree to comply with the policies and procedures of The J Center for Early Learning specified in the Parent Handbook and any other policy statements issued by the school during the year. My signature verifies that all information provided is true and accurate:

Parent Signature - (please type your name as your signature):*

Date:*

Consent:

My Child(ren) has/have my permission to participate in all school sponsored activities and excursions. This includes field trips by bus, car or class walks to nearby points of interest. I will be notified in advance of any off-campus trip, and may be provided with additional permission slips relating to such trips.

I understand that all reasonable measures will be taken to safeguard the health and well-being of the children while at The J Center for Early Learning. The J Center for Early Learning will notify me as soon as possible in the event of an emergency or other reportable matter. However, in the event of an accident I will not hold the school or drivers legally responsible.

In case of sickness or accident, on or off the school grounds, I authorize The J Center for Early Learning or its designee to contact physician(s), medical providers, first responders and others to provide medical or emergency services to care for my child(ren) at my expense. This includes treatment in a hospital emergency room, if such treatment is deemed necessary for the health and well-being of my child.

Additional documentation may be provided at a later date to further the general permission granted in this paragraph.

As parents (guardians), we agree to relieve The J Center for Early Learning of any liability for accident or injury occurring on school premises or on field trips:

Parent 1 Signature - (please type your name as your signature):*

Date:*

Parent 2 Signature - (please type your name as your signature):

Date:

Pictures of my child taken by The J Center for Early Learning may appear in in-house publications (such as newsletters, Facebook, etc.); as publicity for the school; and in our student directory unless I opt out below:
Do not publish photos of my child online.
Do not publish photos of my child in print.

Step 1: Parent Information

Parent 1

Parent 2

Step 2: Child's Information

Select Class: I would like to register my child for: (please select one)

Before and After School Options (paid monthly)

2nd Child's Information

Select Class: I would like to register my child for: (please select one)

Before and After School Options (paid monthly)

Other children in family

Authorized Pick-up Information:

Medical & Other Information:

Signature:

Consent: