DARTMOUTH EARLY LEARNING CENTER
                                        PRESCHOOL APPLICATION
Child's Schedule:_____                                                                       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__________________

BACKGROUND INFORMATION / DEVELOPMENTAL HISTORY


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

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


Name of child’s physician ___________________________________  Tel. # ___________



      

DEVELOPMENTAL HISTORY

Age child began sitting:       crawling:         walking:       talking:

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

If yes please specify:

Any speech difficulties?

Does your child nap, and for how long?

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

What are some of your child’s favorite toys and activities?



Has your child had any previous child care or 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
questionnaire?



What language do you speak at home?

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


What would you like to see included in your child’s preschool program?







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

Eye color                        Hair color                        Height                Weight                
Sex                                Race                                Identifying marks

Physical Disabilities  




REGISTRATION:

A non-refundable annual registration fee of $25.00 is due on the day you enroll your child and should
accompany the application form.


TUITION POLICIES:

The first two month’s tuition must be paid before your child’s first day of school. This eight week non-
refundable deposit is due by June 15th to reserve your child’s space in the program. 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 option.

Once you sign up for a given time slot you are committed to keeping those hours. Any schedule changes
during the course of the school year will require a thirty day notice. Hours may be increased at any time,
however, space permitting. All tuition payments are due on Friday in advance of the coming week or may
be paid monthly at the last week of each month for the upcoming month. After a one week grace period, a
late fee of $10 for each day tuition is not received will be assessed. No student’s tuition may have more
than a two week balance at any time. Any unpaid balance beyond this time will be assessed a finance
charge of 1 1/2 % a month or 18% annually. Enrollment is viewed as a contracted service and is based on
a reserved slot and not on attendance, thus payment is due regardless of attendance. There will be no
charge, however for legal holidays and school vacations. If any family fails to meet its financial
responsibilities beyond a one month balance DELC reserves the right to discontinue service.

WITHDRAWALS:

If you decide to withdraw your child for any reason we require a 30 day notice. At this time all money due
DELC must be paid in full, and your deposit will be applied to the last week your child attends. If at a later
date you decide to re-enroll, a new registration fee and deposit will be due.


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

Parents Signature  _______________________________________              Date ___________








                                                  
AUTHORIZATION SHEET

FOR:____________________________________________________________
CHILD’S NAME

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

EMERGENCY MEDICAL PERMISSION:

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


FIELD TRIP PERMISSION:

(  )  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



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

Parent/Guardian  Signature                                                               Date



PICK-UP AUTHORIZATION
              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


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


FIRST-AID RELEASE:

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


TransportationPlan/Authorization

My child will be dropped off and picked up by parents or someone authorized by parents and not the
Dartmouth Early Learning Center.


Parent/Guardian Signature                                                 Date


NOTICE OF NONDISCRIMINATION POLICY


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.  Toilet training status is not an eligibility requirement for enrollment.  


LICENSING AUTHORITY

The Department Of Early Education and Care(EEC) is the licensing authority for the Dartmouth Early
Learning Center. Their address for our region is 1 Washington St, Suite 20, Taunton, MA 02780, tel.#
508 828 5025.


ANNUAL UPDATE FORM

I have reviewed my child's records and have made any necessary corrections. By signing this form I am
stating that DELC has my permission to:

1. Transport my child to a medical facility and receive emergency medical treatment.
2. Administer basic first aid and/or CPR on my child.
3. Take my child off premises for specified excursions.
4. Apply topical medications listed on the applicable permission forms.
5. Authorize listed individuals to pick up my child from DELC in my absence.


Parent/Guardian Signature                                              Date:


Parent/Guardian Signature                                              Date:


Parent/Guardian Signature                                              Date: