Green Valley Baptist Church
Thursday, July 18, 2019
The Valley is Calling, Come and See...

Enrollment Form

 
 
 
     
 
 
 Little Ed. Learning Center     695 Green Valley Road     Lebanon, VA  24266
2019–2020 SCHOOL YEAR APPLICATION 
 
Select One:                                                                                                                                             
Blue Butterflies’ Preschool ½ dayRed Robin’s Pre-K ½ day  Red Robin’s Pre-K Full Day 
 
Child’s First, Middle, and Last Name: 
Gender:  M F   
Prefers to be called:       
Child’s Birth Date:  
Mailing Address:  
Home Address (if different):  
City, State & Zip:  
Parent Information
Mother’s Name:  
Mailing Address (if differs from child):  
Day Phone: Evening Phone: 
Cell Phone (if different from above):                                       
Can you receive txt msgs?Email address:  
 
Father’s Name:  
Mailing Address (If differs from child):  
Day Phone:  Evening Phone:  
Cell Phone (if different from above):                                        
Can you receive txt msgs? Email address:  
 
 
There is an annual supply fee of $25.00 per student payable during the enrollment process.  Payment should be returned with this completed application and attached document, by mail to above address, or by hand to a staff member of Little Ed. or to the office of Green Valley Baptist Church. 
With completed admission forms, and payment of the supply fee, I understand that Little Ed. Learning Center will reserve a place for my child for the new school year.
 
Parent Signature: 
Date:  
Please make all checks payable to Little Ed. Learning Center.
 
CONFIDENTIAL INFORMATION
 
Your Child’s Name 
 
HEALTH INFORMATION
Does your child have any allergies?  
 
Is there any food that your child cannot eat?  
 
Are there any past illnesses we need to be aware of? 
 
Does your child have any speech or vision problems?  
 
Were there any problems related to toilet-training that we need to be aware of? 
 
Are there any problems with your child’s coordination? 
 
Is your child right or left-handed?  
 
Is there anything we need to be aware of regarding your child’s overall health?  Any special instructions for care or specific concerns?  
 
EMOTIONAL CHARACTERISTICS
Has your child had any previous group or group care experience?  
If so, where?  
 
Were there any issues associated with this experience that we need to be aware of? 
 
Do you foresee any problems with your child’s adjustment to preschool?  
 
How would you describe your child’s personality? 
 
If your child has a tantrum, how do you handle it best? 
 
Does your child have any specific fears or dislikes?  
 
What are your child’s favorite activities or toys?  
 
FAMILY & OTHER INFORMATION
Please list the names and birthdates of siblings, if applicable
 
Is there any other information you would like us to be aware of?  
 
 
 
 
 
Emergency Contact Authorization and Consent
I understand that I am the primary contact and that every effort will be made to reach me in the event of an emergency requiring medical attention for my child   
I understand that the staff of the Center are trained in the basics of first aid and I authorize them to give my child basic first aid treatment.  Should the need arise; I also hereby authorize Little Ed. Learning Center to call an ambulance to transport my child to a hospital or medical facility and to secure for my child the necessary medical treatment.   
Name of Child’s Physician: 
Phone:  
Address:  
I understand that the emergency contact name listing shown below will be used for emergencies and should also be used when my child feels unwell or becomes injured during the school day and requires early pick-up.    Names are listed in order of importance or availability.  
                        Name              Daytime Phone                 Relationship                                                                      (please checkHome/Work/Cell)
 
1.      W  C
    W  C
    
3.     W   C 
      
4.      C
     
5.       C
     
Date: 
Signature of Parent/Guardian: 
Date: 
Signature of Parent/Guardian:   
 
Special Notes:
 
 
 
 
 
 Child Release Authorization
 
Little Ed. Learning Center is authorized to release my child,  to the following individuals, who may pick up my child from the Center during the 2019-2020 school year.  I understand that each authorized person may, at any time, be required to show proper identification.
By signing this form, I understand that Little Ed. Learning Center will not release my child to any other person unless I notify the Center in writing, in advance.  Advance notice may be given during morning drop-off.  Phone calls will not be accepted to authorize release of child to any individual not previously approved.
My child may be released to these individuals:
                        Name              Daytime Phone                 Relationship                                                                      (please check Home/Work/Cell)
 
1.              W  C
     
2.              W C   
                 
3.               C        
     
4.               H W C       
     
5.               C     
      
To ensure children’s safety, Little Ed. Learning Center will release a child only to the parent(s) or legal guardian(s) who have signed this form, and to the persons shown as authorized. 
 
Date:  
Signature of Parent/Guardian: 
Date:   
Signature of Parent/Guardian:  
 
If you wish to add to, or change this list, please inform the Learning Center staff.