Green Valley Baptist Church
Wednesday, December 12, 2018
The Valley is Calling, Come and See...

Enrollment Form

                                                       Little Ed. Learning Center                         
                                                 695 Green Valley Road                           
                                                       Lebanon, VA  24266                                  
                                             (276) 889-0257         
We, at Little Ed. Learning Center, are happy to offer placement for your child in our September - May  school year program.  We would be so pleased to think of starting a new year with you and your family as part of our “Little Ed. Family”.
We’ve included forms to begin the enrollment process.  If you have additional questions at any time, please feel free to call or email.
If we receive your completed application to enroll your child, please know that I will be contacting you again with additional forms and details as we look forward to our Center’s Orientation for students and families scheduled for late August.  We start our new school year on Tuesday after Labor Day.
Thank you for considering our program for your child.  If you join us, I hope that you and your family look forward to this coming new school year with excitement as we do.  
                                                                           Karen Lambert & Staff                                                                                                                          Little Ed. Learning Center
                              Little Ed. Learning Center     695 Green Valley Road     Lebanon, VA  24266
     September - May  SCHOOL YEAR APPLICATION 
Select One:                                                                                                                                             
Blue Butterflies’ Preschool ½ day __  Red 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:  ______________________ EveningPhone:_____________________________ 
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.
Your Child’s Name ____________________________________________________________________________
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?  ________________________________________________________________________________________
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?  ___________________________________________________________________________________________
 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 circle Home/Work/Cell)
1.  ________________     ___________________H/W/C _______________
2.  ______________        ____________________H/W/C  ________________
3.  _______________    ____________________H/W/C __________________
4.  ________________    ___________________H/W/C __________________
5.  ______________         ___________________H/W/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 2017/2018 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 circle Home/Work/Cell)
1.  _______________       ____________________H/W/C  _____________________
2.  _______________       ____________________H/W/C _____________________
3.  _______________       ____________________H/W/C  ____________________
4.  _______________       ____________________H/W/C  ____________________
5.  _______________       ____________________H/W/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.