New Student Registration Please include full addresses including zip codes for anyone you list in this paperwork and promptly update any changes to this information with GLSA administration. Thank you!! Child's Information Childs Last Name First Name Middle Name Nickname Street Address City Zip Code Primary Contact Phone Number Gender Age Birth Date Grade Teacher Name address of school if not a Green Lake Elementary student Parent or Gardian Information Parent/Guardian (required) Parent/Gardian Full Name Relationship to Child Address City Zip Code Home Phone Work Phone Cell Phone Place of Employment Hours of Employment Email Address Parent/Guardian (additional) Parent/Guardian Full Name Relationship to Child Address City Zip Code Home Phone Work Phone Cell Phone Place of Employment Hours of Employment Email Address Emergency Contacts (other than parents or guardians) Please fill out two separate contacts in case of emergency Full Name Full Address city Zip Phone Number Relationship to Child Full Name Full Address city Zip Phone Number Relationship to Child Physician and Dentist Information DEL licensing requires us to have on file the name of your child’s physician and dentist. Please fill this information out in full. It is also a DEL requirement that if your child does not have a physician or dentist that you indicate that and attach a written plan of action you would like us to follow for a dental or medical injury or emergency. Please attach this to your registration paperwork. Childs Physician Full Address Phone Number Date of Last Physical Childs Dentist Full Address Phone Number Date of Last Dental Visit Please describe any special circumstances we should be aware of (medication, allergies, developmental or health concerns) If none please mark N/A: PLEASE NOTE: IF YOUR CHILD WILL NEED TO HAVE MEDICATION ON HAND WHILE ATTENDING GLSA YOU WILL NEED TO REQUEST ADDITIONAL PAPERWORK FROM GLSA STAFF TO BE FILLED OUT BY YOU AND YOUR CHILD’S PHYSICIAN. ANY CHILD THAT NEEDS EMERGENCY MEDICATION FOR LIFE THREATENING ALLERGIES MUST HAVE COMPLETED PAPERWORK AND THE NEEDED MEDICATION ON SITE BEFORE YOUR CHILD CAN START AT GLSA. Restricted Persons Please list any persons who are RESTRICTED from picking up your child (copies of legal documentation must be on file): Name Address Phone Relation Name Address Phone Relation Name Address Phone Relation I give my permission for the following individuals to pick my child up from GLSA: I am aware that it is my responsibility to update this information as needed. Initial Full Name Address Phone Number Relationship to Child Conditions of pick up (ie Tuesdays through the school year, anytime, emergencies, etc) Full Name Address Phone Number Relationship to Child Conditions of pick up (ie Tuesdays through the school year, anytime, emergencies, etc) Full Name Address Phone Number Relationship to Child Conditions of pick up (ie Tuesdays through the school year, anytime, emergencies, etc) Out of State Emergency Contact For use in the event of an earthquake Full Name Address Phone Number Relationship to Child Street Address City State Zip Code Permission to Participate & Consent for Emergency Treatment I hereby give permission for my child to participate in GLSA activities, including activities outside the Center building (field trips). My child is now in good health and may participate in all activities. This permission may be revoked in writing at any time. I further agree to inform GLSA of any changes in my child’s health that may affect his or her ability to participate in certain activities, including field trips. I understand that field trips will sometimes involve transportation by Metro bus or chartered school buses, and hereby give my permission for my child to attend field trips using these forms of transportation. Signature I hereby give permission for my child to be given first aid and emergency treatment by a qualified staff member of GLSA. I also give permission for my child to be transported by ambulance or aid car to an emergency center for treatment. In the event that I cannot be contacted, I further consent to medical, surgical, and hospital care, treatment, and procedures to be performed for my child by a licensed physician or hospital when deemed immediately necessary or advisable by the physician to safeguard my child’s health. Signature I hereby agree and consent to the use of any photographs, video or artwork of my child for recreational purposes such as our projects and activities, advertising or publicity. The items may be used in media such as art projects, bulletin boards, GLSA made movies, GLSA’s website, newsletters, TV, newspaper, etc. I waive all claim to compensation for such use. Signature GLSA School Year Tuition Agreement Please check the days and times that you would like to register your child for (for School Year Only) Monday Morning Yes Tuesday Morning Yes Wednesday Morning Yes Thursday Morning Yes Friday Morning Yes Monday Afternoon Yes Tuesday Afternoon Yes Wednesday Afternoon Yes Thursday Afternoon Yes Friday Afternoon Yes I agree to be responsible for paying my child’s tuition for the days listed above, as well as any other fees incurred on the account (i.e. extra hours, fieldtrip fees, late payments, late pick-ups, vacation care, etc.) I am aware of the following: 1. Payment is due in advance, on the 1st of the month, unless I make other arrangements with the Director. If the payment is received by GLSA after the 5th of the month, I may be subject to a $25.00 late payment charge. Initial If you will need to make an alternate arrangement, such as paying on a date other than the 1st of the month, please specify here: 2. I understand that I am not entitled to a refund or credit for days that my child is ill or not attending because of unplanned absences, vacations, or school closures, scheduled or unscheduled. (Initials) Initial 3. I understand that GLSA closes at 6:00pm. If I, or anyone that I have authorized to pick up my child, arrives after 6:00pm, I will be responsible for paying $1.00 for every minute after 6:00pm that my child remains at GLSA, regardless of whether or not I receive subsidy from a government agency.(Initials) Initial Parent/Guardian WA Drivers License Number Social Security Number (optional) Signature of Parent or Guardian If your tuition will be paid fully or in part by any other agency (City of Seattle, DSHS, UW, etc), or individual, please specify: GLSA Developmental, Social, and Health History We want to provide your child with the best care possible, and be sensitive to any needs that she or he might have. Please help us get to know your child by thoroughly completing this section. Thank You. Eating Would you say that your child generally enjoys eating? What are some of your childs favorite foods? Is your child on a special diet? (Please note: State law requires a form signed by your child’s health care provider if your child has diet modifications) Does your child have food allergies? Please explain. If your child has severe, life-threatening food allergies, please notify us in writing and see the Director for additional medical plan forms. Are there any foods that you do not want us to offer your child? Are there any foods special to your home or culture that you would like to share with our center so that we could make your child more comfortable here? Do you have any concerns about your childs eating habits? Physical Health Please name any surgeries and past illnesses your child has had: Any known medication, insect, or animal allergies? Do you have any concerns about your child's hearing or vision? Does your child use any assistive devices (e.g. glasses, hearing aids, braces) What is your child's primary language? What are the languages spoken in your home? Do you have any concerns about your child's language development? Do you have any concerns about your child's ability to move? Social History Does your child enjoy playing with other children? Does your child enjoy playing alone? What kinds of activities does your child enjoy? What kinds of toys does your child like to play with? How would you describe your child’s temperament and personality? (ex. Quiet, shy, moody, cheerful,easy going, intense, fiery, assertive, thoughtful, impulsive, etc.) What is the best way to comfort your child? How do you guide/teach your child correct behavior? Does your child fear certain things? Upsetting events and losses, such as separation, divorce, or death in the family, can affect a child’s behavior. It helps us to be aware of significant changes in your child’s life so that we can understand and help her/him cope and adjust. Has anything happened that may affect your child’s behavior? If yes, please explain: Who lives at home with your child? Do you have any questions or concerns about your child's social and emotional skills? How can we help ease your child's adjustment to our program? Signature of Parent or Guardian We appreciate any information you can give to assist us in helping your child be happy, healthy and comfortable while at GLSA. To that end if you have anything else you feel it would be helpful for the staff to know in working with your child please explain here. Signature of Parent or Guardian Date
