Returning 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














Parent or Gardian Information

Parent/Guardian (required)











Parent/Guardian (additional)











Emergency Contacts (other than parents or guardians)

Please fill out two separate contacts in case of emergency









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.










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):













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.

















Out of State Emergency Contact

For use in the event of an earthquake









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.


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.


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.


GLSA School Year Tuition Agreement

Please check the days and times that you would like to register your child for (for School Year Only)


Yes


Yes


Yes


Yes


Yes


Yes


Yes


Yes


Yes


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.



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)


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)






GLSA Developmental, Social, and Health Update

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.




If your child has severe, life-threatening food allergies, please see the Director for the appropriate paperwork