ENROLLMENT APPLICATION FORM

Frequently Asked Questions and Answers

When can I register my Child?

Registration is ongoing throughout the school year. If there is no space available you will be placed on the waiting list.

How do I register my Child?

PARENTS MUST COMPLETE EACH DOCUMENT IN THIS APPLICATION PACKAGE BEFORE CHILD CAN BE ADMITTED TO THE CENTER:

1) Pick up an Enrollment Package from the main office

2) Complete all the forms and return them

3) Pay registration fee and tuition

4) Submit child’s immunization record (Georgia Form 3231) and healthy report form.

5) Certificate of Ear, Eye and Dental (3years old and up)

6) Obtain a copy of the center policy

7) Sign center policy agreement

When Do I Pay Tuition?

Tuition is due every Monday before closed of 1^st shift ( 6pm) in the main office.

How Can I become more involved?

1) Join the Parenting Committed meetings are held once per month and see the Director for more information.

2) Look out for general Information and announcement that would be posted on the front door or the classroom door.

Are there any Parent Teachers Conferences?

Parent’s conferences are held twice per year where development assessment of your child’s growth will be made available. Parents can also schedule conferences any time during the year with the teachers or director to review child’s progress.

Which curriculum does the center use?

1) We use the creative curriculum and the AbeKa curriculum

2) You may obtain a curriculum handbook from the main office for detailed information

What are the Tuition rates? (All DFCS subsidies accepted and Scholarship available based on income)

A. First Shift 6:30am-6:00pm:

$50.00 Non-refundable registration fee per year (Academy only)

$35.00 Non-refundable registration fee per year (After School only)

$139.00 Weekly Tuition (Infants)

$129.00 Weekly Tuition (Toddlers)

$114.00 Weekly Tuition (Pre-School)

$65.00 Weekly fee for After School Program

$40.00 Annual enrollment fee will be charged for children two

Years and older (This fee will cover the cost of supplies, books, and student activities.

$110.00 Summer Camp

B. Second Shift 2:00pm-11:30pm :

$50.00 Non-Refundable Registration Fee

$139.00 Weekly Tuition (Infants)

$129.00 Weekly Tuition (Toddlers)

$114.00 Weekly Tuition (Pre-School)

$110.00 Weekly Tuition (After School Program)

$37.00 Drop-in Rate (minimum 3 days only)

Harvest Rain Early Learning Academy

51 Senoia Rd.

Fairburn, GA 30213

TELE: (770) 969-2040 FAX #(770) 969-0574

email: harvestrainintl@aol.com

website: www.harvestrainchurch.org

PARENTS MUST COMPLETE EACH DOCUMENT IN THIS APPLICATION PACKAGE BEFORE CHILD CAN BE ADMITTED TO THE CENTER. PLEASE ATTACH IMMUNIZATION RECORD AND HEALTH REPORT FORM.

ENROLLMENT APPLICATION FORM

(Parents Please Check One)

Day Shift (6:30am-6:00 pm): Night Shift (2:00pm-12:00am):

Entrance Date: ______________ Withdrawal Date: _____________

Child’s Name:

Sex: ________ Age: ___________ Birth Date:

Home Address:

Home Telephone:

Father’s/Legal Guardian Name:

Home Address (If different from above):

City/State/Zip:

Place of Employment:

Employment Address City/State/Zip

Home Telephone: _________________ Work Telephone:

Cell Phone: ____________________

Mother’s/Legal Guardian Name:

Home Address (If different from above):

________________________________ City/State/Zip:

Place of Employment: Employment Address City/State/Zip

Home Telephone: _________________ Work Telephone:

Cell Phone:

Child’s Living Arrangements (Please indicate):

___ Both Parents___ Mother Guardian___ ___ Father ___ Other

Child’s Legal Guardians (Please indicate):

___ Both Parents Guardian___ ___ Mother ___ Father ___ Other

ENROLLMENT FORM (Con’t)

This child may be released to the person(s) listed below:

Name Address

Person(s) to contact in case of emergency, when parents cannot be reached:

Name Relationship Telephone

Name of public or private school child attends, if any:

Child’s Medical Information:

Child’s Physician: _______________________ Telephone #: ___________________

Clinic Name (Primary health source): ________________________________________

Does child have allergies or other physical problems, mental health disorders, mental retardation or developmental disabilities which would limit the child’s participation in the Academy’s program and activities? ____ Yes ____ No

Does child have allergies (insects, medications, foods, etc.):

___ Yes ___ No

If yes, please specify: ___________________________________________________

Are any special procedures required in caring for child?

___ Yes ___ No

If yes, please specify and give dates: _____________________________________

Under the Americans with Disabilities Act of 1991, this program is required to reasonable accommodate individuals with a disability. The reasonable accommodation requirement applies only if the program supervisor is made aware that an accommodation is required. If your child is disabled and require accommodation, you may request it at anytime. This program is also required by Federal law to provide available services without discrimination on the basis of political affiliation, religion, race, color, sex, mental or physical disabilities, (including HIV infection, blindness, deafness, mobility impairments, etc.) If you believe that you have been discriminated against on the basis of the above please contact the U.S. Equal Employment Opportunity Commissions.

Signed: ____________________________ Date: ______________________ Parent/Guardian

Harvest Rain Early Learning Academy

51 Senoia Rd.

Fairburn, GA 30213

PARENTAL AGREEMENTS WITH CHILD CARE FACILITY

1. The Harvest Rain Early Learning Academy agrees to provide care for _________________________________ on _________________________________

Name child is called by Days of week

____________ a.m. to __________ p.m., from _________ to __________________.

(Month) (Month)

My child will participate in the following meal plan (circle applicable meals and snacks):

Breakfast Snack Lunch Afternoon Snack

Before any medication is dispensed to my child, I will provide a written

authorization, which includes: date, name of child, name of medication, prescription number, if any: dosage: date and time of day medication is to be given. Medicine will be in the original container with my child’s name marked on it.

My child will not be allowed to enter or leave the facility without being escorted by the parent(s) (age 18 years and older), person authorized by parent(s) (age 18 years and older), or facility personnel.

I acknowledge it is my responsibility to keep my child’s records current to reflect any significant changes as they occur, e.g., telephone numbers, work location, emergency contacts, child’s physician, child’s health status, infant feeding plans and immunization records, etc.

The facility agrees to keep me informed of any incidents, including illnesses, injuries, adverse reactions to medications, etc., which include my child.

The Harvest Rain Early Learning Academy agrees to obtain written authorization from me before my child participates in routine transportation, field trips, special activities, away from the facility, and water-related activities occurring in water that is more than two feet deep.

I have received a copy and agree to abide by the policies and procedures for the

Harvest Rain Early Learning Academy.

________________________________ Date: ______________________

Parent/Guardian

________________________________ Date: ______________________

Facility Administrator/Person In Charge

Harvest Rain Early Learning Academy (HRELA)

51 Senoia Rd.

Fairburn, GA 30213

TRANSPORTATION AGREEMENT

(After School Enrollees must fill this form out)

This is to certify that I give Harvest Rain Early Learning Academy permission to

transport my child _________________________________

Child’s Name

Pick-up Location (Check One):

□ Palmetto Elementary School

□ E.C. West Elementary School

□ Campbell Elementary School

□ Liberty Point Elementary School

□ Renaissance Elementary School

□ Oakley Elementary School

Time of Pick-up & Delivery

Pick-up: 2:30 p.m. (Regular School Hours)

Pick-up: 11:30 a.m. (Early Release Days)

Delivery Location: HRELA, 51 Senoia Road, Fairburn, GA 30213

Delivery: 3:30 p.m. (Regular School Hours)

Delivery: 12:15 p.m. (Early Release Days)

Days of Pick-up

□ Option 1: Daily ( Mon-Fri)

□ Option 2: Drop-In Check applicable boxes: □ MON □ TUE □ WED □ THUR □ FRI

Parental Agreement

HRELA Transportation Staff is authorized to receive my child. In the event that the authorized person/center is not present to receive my child, the following procedures are to be followed: Contract HRELA Main Office at (770) 969-2040 ext 104.

My child’s Elementary School is approximately 2-3 miles radius from the Academy.

In the event that my child is not to be transported as outlined above: I agree to notify the

HRELA. Failure to notify the center could result in future transportation complications and delays for all children in the After School Program.

Parent/Legal Guardian:_______ Date: _______________

Harvest Rain Early Learning Academy

51 Senoia Rd.

Fairburn, GA 30213

EMERGENCY MEDICAL AUTHORIZATION

Should ______________, suffer an injury

Child’s Name Date of Birth

Or illness while in the care of Harvest Rain Early Learning Academy, and the facility is unable to contact me (us) immediately, it shall be authorized to secure such medical attention and care for the child as may be necessary. (We) shall assume responsibility for payment for services.

I (we) agree to keep the facility informed of changes in telephone numbers, etc. Where I (we) can be reached.

The facility agrees to keep me informed of changes in telephone numbers, etc. Where I (we) can be reached.

The facility agrees to keep me informed of any incidents requiring professional medical attention involving my child.

Child’s primary source of health care is:

____________________________ Telephone: _______________

Physician/Clinic Name

Known medical conditions (i.e., diabetic, asthmatic, drug allergies):

____________________________ Date: ______________________

Parent/Legal Guardian

Home Telephone: ________________

Work Telephone: ________________

Cell Phone: ________________

Harvest Rain Early Learning Academy

51 Senoia Rd.

Fairburn, GA 30213

LIABILITY RELEASE FORM

In consideration for __________________________________ being accepted

Child’s Name

For participation in field trips, special events, daily activities, I do hereby release, forever discharge and agree to hold harmless Harvest Rain Early Learning Academy and the Directors thereof from any and all liability, claims or demands for personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the participant that occur while said person is participating in the above-described trip or activity including recreation and work activities. The undersigned further hereby agrees to hold harmless and indemnify said church, its directors, employees and agents for any liability sustained by said acts of said participant, including expenses incurred attendant thereto.

The aforementioned liability statement also releases HRELA and all employees/board members from any liability in the event that parents/Staff violates HRC policy which prohibits the following conflict of interest actions where: 1) Parents/staff provides childcare services (on the side) for children enrolled in any of the academy’s program; 2) Dating relationship between Harvest Rain staff/parents develops; and 3) Staff signing out or transporting any students enrolled in the academy (per parent permission).

The undersigned further consents to the administration of first-aid and/or doctor’s care, or any other form of medical treatment necessitated by illness or injury that may require the same. In the event of the necessity of such care or treatment as heretofore described, the undersigned agrees to hold harmless and indemnify said church, its Directors, employees and agents from any acts of malfeasance, and/or failure to act on the part of those chosen to administer medical care on behalf of the participant.

, _______________________________________

Parent/Guardian

Signed this ________________ day of ____________________, 20_____

Insurance Company: ________________________________________

Policy Number: ________________________________________

Home Telephone: ______________________________

Work Telephone: _______________________________

Cell Phone: _______________________________

______________________________________

Director’s Signature

Harvest Rain Early Learning Academy

51 Senoia Rd.

Fairburn, GA 30213

INFANT FEEDING PLAN

(Infant Only)

Child’s Name: ___________________________ Date: ______________

Birthday: __________________

Does child take bottle? ___ Yes ___ No

Is the bottle warmed? ___ Yes ___ No

Does the child hold own bottle? ___ Yes ___ No

Can the child feed self? ___ Yes ___ No

Does the child eat (please indicate):

Strained Foods ___ Whole Milk ___

Baby Foods ___ Table Foods ___

Formula ___ Other ___

What type formula used? _______________________________________

Amount of formula to be given: _______________________________________

Updated amounts of formula: __________________ Date: __________

__________________ Date: __________

Does the child take a pacifier? ___ Yes ___ No

When? ________________________________________________

Food child likes: ________________________________________________

Food child dislikes: ________________________________________________

Allergies (which include any pre-mixed formula)? ___________________________

___________________________________________________________________

Child’s Schedule:

Breakfast ________ ____________________________________

Time (Types and approximate amounts of food)

Lunch ________ ____________________________________

Time (Types and approximate amounts of food)

Dinner ________ ____________________________________

Time (Types and approximate amounts of food)

Nap ________

Time

Instructions for the introduction of solid foods or other dietary changes: _____________

______________________________________________________________________

_______________________________________ Date: _____________________

Parent/Guardian

Harvest Rain Early Learning Academy

51 Senoia Rd.

Fairburn, GA 30213

FIELD TRIP PERMISSION

(After School/Pre-School Only)

Dear Parents:

The to ensure all After School/pre-school/K-4 students have adequate physical outside activity the following field trips will be taken through the school and summer year:

Across the street (First Baptist Field) will be used for Field Day Activities daily.

Local Park trips such as: Welcome All Park ( Fairburn) , Carl Miller Park

(Newnan), Wilkerson Mill Park (Fairburn), and Dunkin Park (Fairburn).

The field trips will be taken place between: 7:30a.m. to 6:30pm.

Harvest Rain Agrees to notify parents via written notice posted on the parent information board of the exact day(s) of the above field trips.

□ I give Harvest Rain Permission to Transport my child on the above field trips.

□ I do not give Harvest Rain Permission to Transport my child on the above field trips

________________________________ Date: _________________

Parent/Guardian

Harvest Rain Early Learning Academy

51 Senoia Rd.

Fairburn, GA 30213

VEHICLE EMERGENCY MEDICAL INFORMATION

Child’s Name: ______________________________ Date Of Birth: ______________

Address: ________________________________________________________________

City/State/Zip

Parent’s Name: (Father) __________________________________________________

Home Telephone:____________ Work Telephone:____________ Cell Phone:____________

(Mother) __________________________________________________

Home Telephone:____________ Work Telephone:____________ Cell Phone:____________

In an emergency and parents cannot be reached, please contact:

Name: _____________________________ Telephone: _________________

Child’s Doctor: ________________________ Telephone: _________________

Medical Facility the center uses: Fayette Community Hospital

Address: 1255 Highway 54 West Fayetteville

Fayetteville, Georgia 30214________________________________________________

City/State/Zip

Child’s Allergies: ________________________________________________________

Current Prescribed Medication: __________________________________________

Child’s Special Medical Needs and Conditions: _________________________________

In the event of an emergency involving my child, and if Harvest Rain Early Learning Academy cannot get in touch with me, I hereby authorize any needed emergency medical care. I further agree to be fully responsible for all medical expenses incurred during the treatment of my child.

Child’s Name: ______________________________________________________

Parent/Guardian: ____________________________ Date: ________________

Witnessed By: ____________________________ Date: ________________

Harvest Rain Early Learning Academy

Child Profile

Child’s Name: _______________________ Date: Age:

Please take a moment to complete this profile for your child. This information will help us know your child better and to structure a program to meet his or her individual needs.

1. Has your child had previous preschool experience?

__________________________________________________________________________________________________________________________________________

2. What would you like most for your child to experience with us? __________________________________________________________________________________________________________________________________________

3. What does your child enjoy doing most? ____________________________________

_____________________________________________________________________

4. Do you consider your child shy or outgoing? _________________________________

5. What are your child’s favorite toys? ________________________________________

6. Does your child play with other children? ___ Yes ___ No

If no, please explain: ___________________________________________________

7. List the names and ages of other children in your family:

Name Age

_______________ ____

8. What is the marital status of the child’s parents? _____________________________

9. Who, besides the immediate family, resides in the home? ______________________

_____________________________________________________________________

10. What words are spoken in your home for toileting? ____________________________

11. What language is spoken in your home? ____________________________________

12. How many hours of sleep does your child usually receive a night? ________________

13. Does your child take naps? ___ Yes ___ No If yes, how long? __________

14. Does your child need a favorite item (such as a blanket) for nap? ___ Yes ___ No

If so, does your child have a special name for it? _____________________________

15. Does your child have any special medical or physical needs? __ Yes __ No

If yes, please explain: ___________________________________________________

16. Does your child have any allergies? ________________________________________

17. Do you have a special interest or hobby you would like to share with the children?

__ Yes __ No If so, please explain: ______________________________________

18. Are you available to help us with field trips or other special events? ___ Yes ___ No

Parent’s Signature: __________________________________ Date: _______________

HRLEA and DHR Policies and Procedures/Rules & Regulations Compliance Agreement Form

Early Learning Academy (HRELA) Parenting Handbook and I agree to comply with HRELA

policies and procedures and Department of Human Resources (DHR) rules and regulations.

Learning Academy (HRELA) staff permission (during diaper changing time) to apply

ENROLLMENT APPLICATION FORM

Frequently Asked Questions and Answers

Fairburn, GA 30213

ENROLLMENT APPLICATION FORM

Home Telephone:

Fairburn, GA 30213

PARENTAL AGREEMENTS WITH CHILD CARE FACILITY

Breakfast Snack Lunch Afternoon Snack

Fairburn, GA 30213

TRANSPORTATION AGREEMENT

This is to certify that I give Harvest Rain Early Learning Academy permission to

transport my child _________________________________

Fairburn, GA 30213

EMERGENCY MEDICAL AUTHORIZATION

Should ______________________________, ________________ suffer an injury

Harvest Rain Early Learning Academy

Child Profile

Child’s Name: ___________________________ Date: ________ Age: ____

Should ______________, suffer an injury

Child’s Name: _______________________ Date: Age: