LCA Early Learning Center 2014-2015 APPLICATION

Application Process Step 1

Submit a completed application with a non-refundable application fee of $50 to the elc main office. be sure to sign the statement of cooperation on page four of this form.

Step 2

Submit the following documentation to the ELC Main Office ____Original certified birth certificate ____Original social security card ____Any developmental evaluations or IEP forms ____Custody documentation if student(s) does not reside with birth parents or both parents

Step 3

Once all of the above documentation has been received, our Main Office staff will call you for an interview. Preferably both parents, but at least one parent must interview with the ELC Director.

Step 4

Following the interview, parents must establish a family account by signing a tuition contract and setting up FACTS, should they choose a monthly payment plans.

The enrollment procedure is considered complete when the above paperwork has been filed, an interview has been completed, the financial contract and FACTS have been established, and the school entrance physical with verification of all required immunizations is filed in the ELC office. If the administration can be of any assistance in helping you complete the enrollment process, please feel free to contact us at the number below.

LCA Early Learning Center 100 Mountain View Road, Lynchburg, VA 24502-2272 Phone: (434) 832-2074 (Mon. - Fri. 8:30 a.m. - 4:30 p.m.) * Fax (434) 582-3840 [email protected] * www.LCAbulldogs.com

1. CONTACT INFORMATION ____________________________________________________________________________________________________________ STUDENT LAST NAME FIRST NAME MIDDLE NAME HE/SHE PREFERS TO USE ____________________________________________________________________________________________________________ ADDRESS STREET CITY STATE ZIP COUNTY ____________________________________________________________________________________________________________ AGE DATE OF BIRTH GENDER SOCIAL SECURITY # HOME PHONE ____________________________________________________________________________________________________________ FATHER’S NAME PLACE OF EMPLOYMENT WORK PHONE CELL PHONE EMAIL ADDRESS ____________________________________________________________________________________________________________ MOTHER’ NAME PLACE OF EMPLOYMENT WORK PHONE CELL PHONE EMAIL ADDRESS

MARITAL STATUS MARRIED__________ WIDOWED__________ SEPARATED__________ DIVORCED__________ SINGLE__________ IF SEPARATED, LEGAL GUARDIAN___________________________________________________________________________ Name (Relationship to Child)

HAS YOUR CHILD HAD ANY OTHER CHILD CARE EXPERIENCE? YES__________ NO___________ IF YES, PLEASE GIVE NAME, LOCATION AND TYPE OF CARE____________________________________________________ CHURCH ATTENDING:

NAME/ADDRESS

NAME OF PASTOR

FATHER___________________________________________________________________________________________

MOTHER__________________________________________________________________________________________

CHILD______________________________________________________________________________________________

NAMES OF OTHER CHILD(REN) IN THE FAMILY

AGE

GRADE

SCHOOL ATTENDING

____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________

__________________________________________________________________________________________________ __________________________________________________________________________________________________

__________________________________________________________________________________________________ PATERNAL GRANDPARENTS’ NAME

ADDRESS

__________________________________________________________________________________________________ MATERNAL GRANDPARENTS’ NAME

ADDRESS

2. SCHEDULE DESIRED _____Early Room 7:00-8:00am _____5 half days*

_____5 full days**

_____5 extended care***

_____2 half days TTH

_____2 full days TTH

_____2 extended care TTH

_____3 half days MWF _____3 full days MWF _____3 extended care MWF *A half day runs 8:00 to 12:15

**A full day runs 8:00 to 3:15

***Extended care runs 3:15 to 5:45

3. PERSON TO CONTACT IF PARENTS CANNOT BE REACHED: ____________________________________________________________________________________________________________ NAME WORK PHONE HOME PHONE RELATIONSHIP TO CHILD Persons other than parents who are authorized and have ELC I.D. cards to take child from Center: ____________________________________________________________________________________________________________ NAME WORK PHONE HOME PHONE RELATIONSHIP TO CHILD ____________________________________________________________________________________________________________ NAME WORK PHONE HOME PHONE RELATIONSHIP TO CHILD ____________________________________________________________________________________________________________ NAME WORK PHONE HOME PHONE RELATIONSHIP TO CHILD

IS THERE ANYONE NOT ALLOWED TO PICK UP YOUR CHILD? ____________________________________________________________________________________________________________ NAME RELATIONSHIP TO CHILD

4. MEDICAL AUTHORIZATION __________________________________________________________________________________________ NAME OF CHILD’S PHYSICIAN

PHONE

Does the child have any physical handicaps, disabilities or special medical conditions? Yes______ No______ If yes, please explain:___________________________________________________________________________________________ ____________________________________________________________________________________________________________ Does the child have any known allergies? Yes_____ No_____ If yes, please explain:_________________________________________ ____________________________________________________________________________________________________________ Is the child regularly taking any medication? Yes______ No______ If yes, please explain:____________________________________ ____________________________________________________________________________________________________________ Do you authorize LCA personnel to administer routine medical treatment? (Band-Aid, antiseptic, etc.) Yes______ No______ **DO YOU AUTHORIZE LCA TO SHARE YOUR CHILD’S HEALTH, MEDICAL AND EMERGENCY CARE INFORMATION (i.e., ASTHMA, ALLERGIES, DIETARY NEEDS, ETC) WITH THE DIRECTOR OF THE EARLY LEARNING CENTER AND YOUR CHILD’S TEACHERS? Yes_____ No______ If “NO”, please return to the school in a sealed envelope addressed to LCA school nurse.

The ELC agrees to notify the parent/guardian whenever the child becomes ill, and the parent/guardian agrees to pick up thereafter as soon as possible. In case of accident or emergency illness, the Early Learning Center will make every effort to contact the parent or guardian. If contact cannot be made, parent or guardian hereby authorizes LCA and/or medical personnel to render treatment, which in their judgment, is deemed necessary in the care of this child. Agreed to this____________________ Day of____________________ 20____________________ By_____________________________________________________ SS#____________________________________________________ Parent or Guardian

By_____________________________________________________ SS#____________________________________________________ Parent or Guardian

5. DISCRIMINATION POLICY No person shall be denied enrollment, be excluded from participation in, be denied the benefit of or subject to discrimination in any program or activity, on the basis of sex, race, color, national origin or ethnic group. For the safety and well-being of our students and employees, students and/or employees with a life threatening communicable disease may not attend or work at LCA. Decisions regarding attendance or employment will take into account multiple medical professionals with expertise in the disease. As a Bible based educational institution, LCA adheres to the Biblical teaching that homosexuality is not an acceptable lifestyle. LCA does not employ teachers or accept students who are homosexual or bi-sexual.

6. COMPLIANCE AGREEMENT In compliance with Virginia Law, no student will be considered enrolled nor permitted to attend for whom a certified copy of the student’s birth record (or affidavit explaining inability to present a certified copy) and a complete school entrance physical (to include verification of required immunization) have not been received. A late processing fee of $25 will be applied to the account of any student for whom the Virginia School Entrance Health Form has not been received by June 1, by 15 working days after notification of acceptance or by the first day of attendance, whichever date occurs first. If the deadline cannot be met due to insurance requirements or acceptance after June 1, contact the ELC at (434) 832-2074 with the date it will be completed.

7. ELC STATEMENT OF COOPERATION 1.

In full cooperation with The Early Learning Center, we will attend the parent sessions and family events planned by the Center. We sincerely pledge our loyalty to the aims and ideals of the school and will bring all questions and criticisms directly to the administration so that they may be properly considered by those in authority.

2.

Parents will pay tuition as stated on the ELC contract.

3.

I will submit all results of developmental evaluations to the ELC.

4.

The faculty and administration are hereby given full discretion in the discipline of our child. This would include using the time-out chair, notes and phone calls to parents, and conference with the director.

5.

The school reserves the right to dismiss any student who does not cooperate with Early Learning Center policies or any parent who does not cooperate with Early Learning Center policies. We understand that all students are accepted on a six week trial basis.

6.

It is our understanding that the policy for the school is to make no refund on fees. Tuition may only be waived by the director upon withdrawal if an exception is made. Otherwise, tuition is due in full, regardless of attendance.

7.

We hereby authorize the Early Learning Center to permit our child to participate in all school activities, including but not limited to school sponsored field trips away from the school premises, and absolve the school from liability to us or our child because of any injury to our child at school or during any school activity.

8.

We agree to notify the LCA Early Learning Center promptly of any change in our address, telephone, employment, or marital status.

9.

We have read the Principles and Policies Handbook for the Early Learning Center in its entirety, and are in full agreement as so stated.

10. Pictures – I hereby grant LCA permission to use my son or daughter’s photograph in print, electronic and video formats or in other official LCA print publications and I acknowledge LCA’s right to appropriately crop and/or correct the photograph as needed. LCA has the right to reproduce, use, exhibit, display, broadcast, distribute and create derivative works of the photographed images of your son or daughter for USE IN CONNECTION WITH THE ACTIVITIES OF THE ACADEMY FOR PROMOTING, ADVERTISING, PUBLICIZING, OR EXPLAINING LCA OR ITS ACTIVITIES.

____________________________________________________________________________________________________________ Parent Signature Date

LCA Early Learning Center 100 Mountain View Road, Lynchburg, VA 24502-2272 Phone: (434) 832-2074 (Mon. - Fri. 8:30 a.m. - 4:30 p.m.) * Fax (434) 582-3840 [email protected] * www.LCAbulldogs.com