GLORIA DEI EARLY CHILDHOOD MINISTRY 2016-2017 Registration Procedures and Information Sheet Our Mission: Helping one another live life with Jesus every day Thank you for your interest in the Early Childhood Ministry at Gloria Dei Lutheran Church. Please read the guidelines and follow the information sheet carefully. If you have any further questions, please contact the ECM Office at (281) 333-3323, email Kathie Walker at
[email protected] or visit our website at www.gdlc.org. REGISTRATION PROCEDURES First:
Pick up a Registration Form. Print or type ALL requested information (N/A may be used) on the forms.
Second:
Please return your completed Registration Form with a $50 non-refundable Application Fee beginning Monday, February 15, 2016 at 7:00 AM to the Early Childhood Ministry Office. Applications will be reviewed for completion before being accepted. Applications will be considered in the order received.
Third:
After receipt of application, an Acceptance Letter and Enrollment Packet will be emailed to you.
Fourth:
Within two weeks of receiving your Acceptance Letter the following is required: 1) A non-refundable Enrollment Fee of $200.00. This fee is a yearly fee to secure enrollment placement and is NOT applied toward tuition. 2) Enrollment Packet includes: Church Information Form; Health Statement; Current Immunization Form; and Volunteer Form. 3) A copy of child’s insurance card. 4) A birth certificate from the Bureau of Vital Statistics (for new children enrolling). Failure to remit Enrollment Fee and Packet will result in forfeiture of your child’s enrollment status, which will automatically place your application into the waiting pool.
REGISTRATION DATES AND GENERAL INFORMATION Acceptances will reflect availability and ratios set forth by the National Lutheran School Association and the Department of Texas Child Care Licensing. If your first preference cannot be accommodated and you do not mark a second choice, your application will be put into the waiting pool for your first choice (only). You may submit any concerns regarding your child’s need in writing to the Director. This information will be taken into consideration with your child’s classroom placement. Please detach this form from the Registration Form and retain it for your records
Our Mission: Helping one another live life with Jesus every day GLORIA DEI EARLY CHILDHOOD MINISTRY 2016-2017 Registration Form PLEASE COMPLETE ALL INFORMATION Child's Name __________________________________________________ Gender _________ Date of Birth ________________ Age as of September 1, 2016 _____________________________________ Baptized ( ) Y ( ) N Interested in Baptism ______ Mailing Address ________________________________________________ City ___________________ , Texas Zip _________ Primary E-mail (s) __________________________________________ Preferred Contact Method
Indicate 1st and 2nd Choice of Days Attending: ( ) TTh – Infant thru PS3 only ( ) MWF
( ) E-Mail
( ) M-F
( ) Phone ( ) ____________ *
* Alternate schedules considered on individual basis due to limited availability – MUST select a second choice
Indicate Arrival and Departure Time: Before School Care ( ) 6:30-9 AM ( ) 8-9 AM School Hours (X) 9-12 Noon After School Care ( ) 12-1 PM ( ) 12-2 PM ( ) 12-3 PM ( ) 12-4 PM ( ) 12-5 PM ( ) 12-6 PM
Names of Parents: Mother ________________________________ Or Guardians Employer * _____________________________
May we contact you at work? (Yes) (No) (Emergency Only) Phone __________________________________________
Cellular Phone ___________________________ E-mail __________________________________________ Father _________________________________
May we contact you at work? (Yes) (No) (Emergency Only)
Employer * _____________________________ Phone __________________________________________ Cellular Phone __________________________ E-mail __________________________________________ * Concealed firearms are not allowed on the premises. I am licensed as a federal/state law enforcement agent ( ) Yes ( ) No. If yes, I may be carrying a firearm ( ) Yes ( ) No.
Please Initial
. Parent's status
( ) Married
( ) Separated
( ) Divorced
( ) Widowed
( ) Single Parent
If divorced, who has custody? _____________________________________________________________________________ Does law prevent us from releasing this child to either parent? ( ) Yes - A copy of the court order must be in our files.
( ) No
Please Initial List emergency contacts in priority order that also have the authority to pick up your child: 1. ___________________________________________________ Phone # (s) _______________________________________________________ 2. ___________________________________________________ Phone # (s) _______________________________________________________ 3. ___________________________________________________ Phone # (s) _______________________________________________________ 4. ___________________________________________________ Phone # (s) _______________________________________________________ 5.. ___________________________________________________ Phone # (s) _______________________________________________________
Unfamiliar persons authorized to pick up your child will be required to provide a valid Driver's License or other picture I.D. before child is released to them. Children will not be allowed to leave with any other person without authorization from the responsible parent or guardian.
Please Initial ****************************************************************************************************** FOR SCHOOL USE ONLY: Age Group __________ Entry Date __________ KES # __________ Notes ___________________________________________
TRANSPORTATION: I hereby ( ) give ( ) do not give consent for my child to be transported and supervised by Gloria Dei ECM for Medical Emergency / Emergency Evacuation I hereby ( ) give ( ) do not give consent for my child to be transported and supervised by Gloria Dei ECM on Field Trips in the Prekindergarten age level only
Please Initial WATER ACTIVITIES: I hereby ( ) give ( ) do not give my consent for my child to participate in water sprinkler activities.
Please Initial PHOTOGRAPHS/VIDEO TAPING: I hereby ( ) give ( ) do not give consent for my child to be photographed and/or videotaped for any legitimate purpose including but not limited to the classroom (including scrapbook) / ECM program / Gloria Dei purposes.
Please Initial HIPAA PRIVACY POLICY ACKNOWLEDGEMENT: I hereby ( ) give ( ) do not give my consent to disclose my child’s health information as necessary to administrate the health and safety of the program.
Please Initial 1. 2. 3. 4. 5. 6.
SPECIAL NEEDS AND MEDICAL HISTORY Does your child have any medical condition, existing/previous serious illness or injuries? ( ) Yes ( ) No If yes, please indicate what it is: _________________________________________________________________________ Is your child on any medication prescribed for long term or continuous use? ( ) Yes ( ) No If yes, please indicate what it is: _________________________________________________________________________ Does your child have any allergies (food, drug, environmental)? ( ) Yes ( ) No If yes, please indicate what it is: __________________________________________________________________________ Does your child have any vision, speech, or hearing problems? ( ) Yes ( ) No If yes, please indicate what it is: _________________________________________________________________________ Does your child have any special needs? ( ) Yes ( ) No If yes, please indicate what it is: ________________________________________________________________________ Is there any other information that the faculty should be aware of? ( ) Yes ( ) No If yes, please indicate what it is: _________________________________________________________________________
EMERGENCY INFORMATION In case of a medical emergency while my child is attending the Gloria Dei Early Childhood Ministry, I understand that the following procedure will be followed: 1. 2. 3. 4. 5.
The program will contact parent(s) at the telephone numbers listed on the registration form. If neither parent is available in an emergency, the program will contact the emergency contacts listed below. The program will provide first aid and take appropriate measures including contacting Emergency Medical Services. The program will arrange for an ambulance or other emergency vehicle to the preferred hospital listed below (or the nearest emergency medical facility, if necessary). The program may contact my child’s physician at the telephone number given below.
Please list persons, other than parents, to contact in case of an emergency (someone who will usually know your location). Name__________________________________________________ Relationship to Child ____________________________ Phone Number _________________________________________ Any Other Information?______________________________ Name__________________________________________________ Relationship to Child ____________________________ Phone Number _________________________________________ Any Other Information?______________________________
If a medical emergency arises and a parent/guardian or persons designated above cannot be reached, I hereby authorize the ECM Faculty and/or Gloria Dei Staff to authorize permission for emergency medical treatment from my child's physician, emergency medical corps, and/or local hospital to follow the above procedure . Please Initial Child's Physician ________________________________________________ Phone ________________________________________________ Hospital Preference (indicate specific location) _____________________________________________________________________________ Medical Insurance Provider ______________________________________ Insurance #_____________________________________________
For the health and safety of your child, please keep your child’s information current at ALL times. Did another Gloria Dei ECM family refer you? ( ) Yes ( ) No. If yes, which family? ____________________________________ If no, how did you learn about our program? ___________________________________________________________________________
PARENT’S SIGNATURE _____________________________________________ DATE
_________________________
2016-2017 Early Childhood Ministry Tuition Rates Monthly Fees for Infants
Age: 0-11 Months
To figure Tuition, start with the Primary Schedule,
6:30 AM
9:00 AM
6:00 PM
3:00 PM
1
$222
$116
TTh
2
$444
$232
MWF
3
$666
$348
4
$888
$463
5
$1,110
$579
6:30 AM
8:00 AM
9:00 AM
12:00 PM
12:00 PM
12:00 PM
12:00 PM
12:00 PM
12:00 PM
6:30 AM
9:00 AM
9:00 AM
12:00 PM
1:00 PM
2:00 PM
3:00 PM
4:00 PM
5:00 PM
6:00 PM
6:00 PM
1
$46
$18
$77
$18
$37
$55
$74
$92
$110
$233
TTh
2
$92
$37
$154
$37
$74
$221
$147
$184
$221
$467
MWF
3
$138
$55
$231
$55
$110
$166
$221
$276
$331
$700
4
$184
$74
$307
$74
$147
$221
$294
$368
$442
$933
5
$230
$92
$384
$92
$184
$276
$368
$460
$552
$1,166
Days
M-F
of 9 AM-12 PM (fee in the highlighted column) and add appropriate Before School Care (6:30-9 AM) and/or After School Care (12-6 PM) fee options. All Infant through PK fees include a hot lunch. Monthly Fees for Toddlers
Days Age: 12-24 Months
M-F
Monthly Fees for Preschool Students 6:30 AM
8:00 AM
9:00 AM
12:00 PM
12:00 PM
12:00 PM
12:00 PM
12:00 PM
12:00 PM
6:30 AM
9:00 AM
9:00 AM
12:00 PM
1:00 PM
2:00 PM
3:00 PM
4:00 PM
5:00 PM
6:00 PM
6:00 PM
1
$46
$18
$80
$34
$52
$70
$89
$107
$126
$251
TTh
2
$92
$37
$160
$67
$104
$141
$178
$214
$251
$503
MWF
3
$138
$55
$240
$101
$156
$211
$266
$322
$377
$754
4
$184
$74
$320
$134
$208
$281
$355
$429
$502
$1,006
5
$230
$92
$399
$168
$260
$352
$444
$536
$628
$1,257
Days Age: 2 & 3 Years
M-F
Monthly Fees for Prekindergarten Students 6:30 AM
8:00 AM
9:00 AM
12:00 PM
12:00 PM
12:00 PM
12:00 PM
12:00 PM
12:00 PM
6:30 AM
9:00 AM
9:00 AM
12:00 PM
1:00 PM
2:00 PM
3:00 PM
4:00 PM
5:00 PM
6:00 PM
6:00 PM
1
$46
$18
$80
$34
$52
$70
$89
$107
$126
$251
2
$92
$37
$160
$67
$104
$141
$178
$214
$251
$503
MWF
3
$138
$55
$240
$101
$156
$211
$266
$322
$377
$754
M-Th
4
$184
$74
$320
$134
$208
$281
$355
$429
$502
$1,006
M-F
5
$230
$92
$399
$168
$260
$352
$444
$536
$628
$1,257
Days Age: 4 & 5 Years
Unscheduled care with prior approval is provided for a $8.00 per hour fee
The ECM is a non-profit ministry of Gloria Dei Lutheran Church Fees Families are required to submit an annual, non-refundable $50 Application Fee per child with Registration Form. Upon acceptance into the ECM an annual, non-refundable $200 Enrollment Fee per child is required.
A 15% discount is offered (only) to a sibling(s) with the lowest tuition rate(s). A 15% discount is offered to parents actively serving in the Military. Eligible families are able to select only one form of the discounts offered.
Discounts are not applied to the Application or Enrollment Fees.
An additional 1% Administrative Fee will be assesed for families not participating in Simply Giving.
