PRIMARY GRADES APPLICATION
                                                                                                         Admission Date:_____

Child’s name       ____________________________            D.O.B. ____________________

Mother’s name_______________________________  Tel ______    Email:_____________

Address _______________________________________________________________

City ___________________________________________________   Zip  ___________

Employment ____________________________________________  Work# __________

Father’s name ______________________________________________  Tel. ________

Residence( if different) ____________________________________________________

Employment _____________________________________________   Work# _________

Names and ages of other children in family

Names of other members of the household

If parents can’t be reached in emergency, call:

Name ________________________  Tel. ________ Relationship__________________

Name ________________________  Tel. ________ Relationship__________________

Name ________________________  Tel. ________ Relationship__________________


Applicant’s health; Are there any allergies or points requiring special attention?

Any serious illness or hospitalization?

Any medication given regularly?

Special instructions in case of illness

Name of child’s physician ___________________________________  Tel. # ___________

Has your child had an eye test?                                A hearing test?

Does your child have any special needs you are aware of?

If yes please specify:

Does your child have any pets?                        What kinds and what are their names?

Has your child had any previous  preschool experience?
Where, and how long?

Can you give us a description of your child and/or any other pertinent information not included in this

What language do you speak at home?

What family background, beliefs or traditions would be relevant to making your child’s experience here more

What would you like to see included in your child’s kindergarten or  primary grades program?

IDENTIFYING INFORMATION ( Required by the Department of Early Education and Care)

Eye color                        Hair color                        Height                Weight                
Sex                                Race                                Identifying marks

Physical Disabilities  


Finances/Tuition Policy

The cost for the primary program is $7000 for the 2014/2015 school year. This tuition covers the 9-3 school
day. Children may be left as early as 8 am and picked up as late as 5:00 pm.  Extra hours are assessed a
charge of $6.00 per hour or any part of an hour.  (Kindergarten tuition is tax-deductible.)

A two-month non-refundable deposit is due by May 15th.  Space is limited and early registration
is encouraged.  After this initial deposit there are three payment plans from which to choose.

Option 1
 If you choose this option, you continue to pay monthly installments, but with a 5% service fee added to
each invoice. Payments are due the last week of each month for the upcoming month.

 Option 2
   If you choose this option, the second three installments representing the first half of the school year will
be due by September 15 and you will receive a 3% discount for this semi-annual plan. The second half
amount for this plan will be due by January 15.

   Option 3
   Option 3 is the annual plan. The full 10 installments are due by June 15th. There is a 5% Discount for this

After a one week grace period, a late fee of $10 for each day tuition is not received will be assessed.
Enrollment will be subject to cancellation if an account becomes two months past due.  Any unpaid balances
will be assessed a finance charge of 1 1/2 % a month or 18% annually. In addition to the daily late fees, any
unpaid balance beyond this time will be assessed a finance charge of 1 1/2 % a month or 18% annually.  
There will be a $20 service charge to cover bank fees for any checks returned to us for insufficient funds.  
By enrolling your child you agree that you have read and understand DELC tuition policies and agree to
meet your financial obligations. By enrolling your child you also agree to pay this annual amount whether
your child attends the entire school year or any part of it. All reasonable collection charges, including
attorney fees, will apply to delinquent accounts.

I have read and understand the DELC tuition policies and agree to meet my financial responsibilities.

Parents Signature ______________________________          Date __________



It is our policy to keep at school the following authorizations in the best interests of your child and in
compliance with EEC regulations.


I hereby give the DELC permission to take my child to St. Luke’s Hospital for medical treatment when I
cannot be reached or when delay would be dangerous.

Parent/Guardian Signature                                                         Date

Updated                     Initials                     Updated                       Initials


(  )  I am willing to have my child taken on field trips either on foot or in an authorized vehicle, supervised by
the personnel in charge at DELC.  I understand that notice will be given before each trip.

Parent/Guardian Signature                                                         Date

Updated                    Initials                     Updated                    Initials

(  ) I am not willing to have my child taken off the school grounds for any field trip.  

Parent/Guardian  Signature                                                               Date

                      Name                        Tel.                                  Reltn.

I hereby authorize

to pick up my child at the Dartmouth Early Learning Center in my absence.  I have notified these people and
they realize they must identify themselves before they can receive my child.  I will send a note or call ahead
to inform the school if there are any changes in these arrangements.

Parent/Guardian Signature                                                           Date

Updated                     Initials                   Updated                        Initials

List here any special instructions or names of anyone who are never authorized to pick up your child:

I understand that the staff at DELC is trained in first-aid, and I give my permission for them to administer first-
aid as needed.

I further understand that I will be notified whenever first-aid has been administered.

Parent/Guardian Signature                                                 Date

Updated                  Initials                    Updated                   Initials


The Dartmouth Early Learning Center admits students of any race, religion, national and ethnic origin.  It
does not discriminate in providing services, educational programs, or admissions to children and their
families on the basis of race, religion, cultural heritage, national origin, disability, political beliefs, sexual
orientation, or marital status.    


The Department Of Early Education and Care(EEC) is the licensing authority for the Dartmouth Early
Learning Center.