Office Use: Date Received by HPS Office__________________

Heintz Preschool of Congregation Agudas Achim Application for Enrollment & Tuition Agreement 2016-2017

16550 Huebner Road San Antonio TX 78248 (210) 479-0429 c.geideshman @a g u d a s - a c h i m . o rg

Child’s Child’sFirst Name:

Last Name:

Date of Birth:

Age: (As of September 1, 2016) 0 Male 0 Female

Home Phone:

Child’s Address:

City:

Zip:

Class Information: 0 New Enrollment 0 Returning Student (Please state last year and class )

Parent Name

Address

Phone (w) Cell

Email

Place of Business

Religious Affiliation

Parent Name

Address

Phone (w) Cell

Email

Place of Business

Religious Affiliation

How did you hear about our school? Advertisement Walk in Referral If referred, whom may we thank?_________________________________________________

*May we include your child’s name, parents’ names, home phone number and address in our directory? 0 Yes 0 No

*May we include your child’s picture in advertising, no names are mentioned? 0 Yes 0 No*May we include your child’s picture on CAA’s Facebook page, no names are mentioned? 0 Yes 0 No

Emergency Information School Year 2016-2017

Child's Last Name Child's First Name

Allergies Medication

Home Address Home Telephone Number

Parent InformationMother’s Name: Father’s Name:Mother's Work Telephone: Father’s Work Telephone:Mother's Cell: Father's Cell:Mother's E-mail: Father's E-mail:

Emergency Contacts:Name #1 : Name #2 :Telephone: Telephone:

Child's DoctorDoctor's Name: Doctor's Address:Doctor's Telephone:

Insurance Information:Name of Insurance: Policy #

Authorized persons to pick up child:Name #1 Phone #Name #2 Phone #Name #3 Phone #*Please remind anyone who is picking the child

Is there anyone unauthorized to pick up your child?#1#2

Heintz Preschool of Congregation Agudas Achim Registration Fee Information

2016-2017

Registration and Supply Fees and Hours:

1. A one-time non-refundable registration fee of $250 is required when the registration form is returned.

Supply fees vary according to class and are due with the child’s first installment of tuition. ** Children are not considered registered at Heintz Preschool until registration fees are paid. **

2. All primary members qualify for a 15% tuition discount or one sibling qualifies for a 10% tuition discount. **Discount not applicable to the registration fee, supply fee, and extended care fee ** 3. Late fees for picking up your child will be billed to your account at the rate of $1 per minute after 3pm.

Tuition is calculated on a yearly basis. Credit card or bank debit authorization forms will be kept on file to pay for your child’s tuition unless other arrangements are made with the business office.

A signed Tuition Agreement (enclosed) must accompany this

registration form. Thank you!

Parent/Guardian Name Parent/Guardian Signature Please print

16550 Huebner Road San Antonio TX 78248 (210) 479-0429 c.geideshman@agudas-achim.org

Heintz Preschool would like to make your entire family part of our preschool family.

Throughout the year, the preschool has special events and fundraisers.

We would like to invite your family members to participate in these

special activities. Please fill out the following information andreturn it with your child’s registration form.

Grandparents

Name: Address: P

E

Name: ___________________________ Address: __________________________Phone: ___________________________Email: ___________________________

16550 Huebner Road San Antonio TX 78248(210) 479-0429 c.geideshman@agudas-achim.org

Tuition Information and Agreement

The Congregation Agudas Achim Board of Trustees approves the school’s tuition each year. It is reasonable and typical to expect annual tuition increases to offset increases in operating costs.Heintz Preschool of Congregation Agudas Achim offers several options for tuition payment. Our tuition is based on a full school year. We break payments into even installments for your convenience.

AnnualThe annual tuition payment is due August 1.The Business Office accepts cash, checks and most credit cards.In the event a student does not complete the entire school year, a 30 day notice of withdrawal must be submitted to the school director and the CAA Board of Trustees. Pre-paid tuition is refundable onlyfor the complete months a f t e r withdrawal; partial months will not be credited. (e.g.: a student moveson March 15, balance after April 1 will be credited).

Semi-annualThe semi-annual payment option splits the tuition in half.The first payment is due August 1 (or upon enrollment), and the second is due January 2. The Business

Office accepts cash, checks, and most credit cards.Tuition for students enrolling after the school year begins will be prorated. The prorated portion of thetuition will be divided evenly into two installments to begin upon enrollment and ending no later than May 1.

In the event a student does not complete the entire school year, a 30 day written notice of withdrawal must submitted to the school director and the CAA Board of Trustees. Pre-paid tuition is refundable only for the complete months a f t e r withdrawal; partial months will not be credited. (e.g.: a student moves on March 15, balance after April 1 will be credited).

Ten-installment The ten-installment tuition plan will start on August 1 (or upon enrollment, after this date). All payments are due on or before the 1st of each calendar month.

Tuition is based on a full school year and is divided to reflect 10 equal installments. Tuition for students enrolling after the school year begins will be prorated. The prorated

portion of the tuition will be divided evenly into adequate installments to begin upon enrollment and ending no later than May 1.

In the event a student does not complete the entire school year, tuition must be paid in full for the month the student withdraws. A 30 day written notice must be given to the school director and the CAA

Board of Trustees regarding withdrawal.If tuition lapses more than one installment, a student will be ineligible to attend classes unless prior payment arrangements have been made with the business office.

I acknowledge that I have received this information and understand it. Date:

Parent/Guardian Name Parent/Guardian Signature Please print

Tuition & Payment InformationDate received by office: Student Name:

Class Room (Circle): Purple (18mo-2yrs) Yellow (2-3yrs) Blue (3-4yrs) Red (4-5yrs)

Classes are open to children ages 18 months and older as of September 1, 2016. Children must be of age by September 1 for the year in which they are enrolling.

Pl e as e Ci r c l e The preferred schedule for your child:

Registration Fee– Due at time of RegistrationNon-RefundablePlease Initial:

Supply Fee- Due with first Installment

10-Month Tuition Installment Plan Charged the 1st of the month

Bi-Annual Tuition First Payment– August 1st Second Payment- January 1st

Annual Tuition Extended Care Options:Circle OR State estimated time

2 Day/Week 9am-3pm

$250 $100 $410 $2,050 $4,100 AM

PM

3 Day/Week 9am-3pm

$250 $125 $500 $2,500 $5,000 AM

PM

5 Day/Week 9am-3pm

$250 $150 $700 $3,500 $7,000 AM

PM

Pre-K5 Day/Week

9am-3pm

$250 $150 $700 $3,500 $7,000 AM

PM

Young Explorers - Sign up to extend your child's day!

BEFORE AND AFTER SCHOOL CARE OFFERED MONDAY - FRIDAY

Early Stay: 7:30 am—9:00 am After Stay: 3:00 pm– 6:00 pm $15.00 Per Hour

Daily sign up is also available and will be billed to your monthly statement. Simply give us a call if you are running late or need extra some extra time.

*If prior arrangements have NOT been made, late fees will be billed to your account at the rate of $1 per minute after 3:10 pm.

**PLEASE SEE ATTACHED SHEET FOR AFTER SCHOOL ENRICHMENTS**

Member Discount: 15% Or Sibling Discount: 10% (One per

Family) (select one discount, does not apply to extended care)

Method of Payment:

Bill my Account

Or Check #

Please bill my: Visa MC Am Ex For a Total of $

Name on Card:

Billing Address & Zip Code:

Credit Card Number:

Exp Date:

Signature of Card Holder:

16550 Huebner Road San Antonio TX 78248

PR ES C HOOL P E R SO NA L R E C O R D Teacher’s File

Date:

Child’s Name:

Name child likes to be called: Birthdate:

Sibling(s) Name: Age:

Age:

P E R SON A L HIS T O R Y :

Does child walk well? Yes No

Run? Yes No

Is your child a good climber?

Does your child fall easily?

Talking? Yes No

In phrases? Yes_ _No

In sentences? Yes No

Does your child speak any other language? If yes, which

H E A LT H HIS T O R Y :

Physical Disabilities? Yes No

Serious Illnesses? Yes No

Known Allergies? Yes No

Other Conditions or Limitations

Pr e s c h o o l Pe r so na l R e c o r d P a g e 2

Is your child toilet trained? Yes No In the process of being trained? Yes

No

If yes, are you using a potty chair ? Toilet seat ?Does your child have frequent toilet accidents? Yes No How does your child react to accidents?

Does your child let you know when he/she needs to use the toilet?Defecate word Vomit word

Urinate word

S L EE P ING H A B IT S :

What time does your child go to bed? Awaken?

Does your child have his/her own room? Yes No

Is your child accustomed to napping? Yes No

What is your child’s nap schedule?

What is your child’s mood on awakening?

Does your child sleep with a special toy or blanket?

SOCI A L R EL A T I O N S:

Does your child spend time with both parents?

If you are separated/divorced, how often does your child see the absent parent?

Has your child had experiences playing with other children?

By nature, is your child: Outgoing? Shy?

Aggressive? Withdrawn?

Does your child enjoy being alone? Yes No

How does your child relate to strangers?

What makes your child upset?

How does your child show his/her feelings?

Preschool Personal Record Page 3

What do you find is the best way to discipline your child?

How do you comfort your child?

Is your child frightened by any of the following:Animals? Storms?

Dark? Loud or Sudden Noises?

Other Fears?

Does your child like animals?

Is your child allergic to any types of animals or pets?

Have there been any tragedies, family stresses, unusual emotional occurrences, etc., that we should be aware of to assist us in teaching and playing with your child? Yes No Please describe:

E A T IN G :

Please list any foods or beverages your child is allergic to:

Does your child have any eating problems? What are your child’s favorite foods?What does your child dislike?Do you give your child?

Does your child use a spoon? Any dietary restrictions?

Popcorn Raw CarrotsRaw CeleryPeanuts Peanut Butter

A fork?

O T H E R I N FORM A T ION :

What are your child’s favorite toys? Interests? Activities?

What are your expectations of your child’s experience in the He i n tz P re s chool program and how can we meet them?

Texas Dept of Family and Protective Services

Form 2935Aug 2010 / Pg 1 of 3

ADMISSION INFORMATION

Signature – Parent or Legal Guardian Date

Operation Name Director’s Name

Child’s Full Name Child’s Date of Birth Child’s Home Telephone No.

Child’s Home Address

Date of Admission Date of Withdrawal

Parent’s or Guardian’s Name Address (if different from child’s address)

List telephone numbers below where parents/guardian may be reached while child will be in care:Mother’s Telephone No. Father’s Telephone No. Guardian’s Telephone No. Cell Phone No

Give the name, address and phone number of person to call in case of an emergency if parents / guardian cannot be reached: Relationship

I hereby authorize the childcare operation to allow my child to leave the childcare operation ONLY with the following persons. Please list name &telephone number for each. Children will only be released to a parent or a person designated by the parent/guardian after verification of ID.

CHECK ALL THAT APPLY: I hereby give do not give consent for my child to be transported and supervised by the1. TRANSPORTATION: operation’s employees:

Walk home for emergency care on field trips to and from home to and from school

2. FIELD TRIPS:Parent’s Comments:

I hereby give do not give my consent for my child to participate in Field Trips:

3. WATER ACTIVITIES: I hereby give do not give my consent for my child to participate in Water Activities:

sprinkler play splashing/wading pools swimming pools water table play

4. RECEIPT OF WRITTEN OPERATIONAL POLICIES:I acknowledge receipt of the facility’s operational policies including those for discipline and guidance.

5. I UNDERSTAND THAT THE FOLLOWING MEALS WILL BE SERVED TO MY CHILD WHILE IN CARE:None Breakfast AM Snack Lunch PM Snack Supper Evening Snack

6. MY CHILD IS NORMALLY IN CARE ON THE FOLLOWING DAYS AND TIMES:Mondays from: to:Tuesdays from: to:Wednesdays from: to:Thursdays from: to:Fridays from: to:Saturdays from: to:Sundays from: to:

AUTHORIZATION FOR EMERGENCY MEDICAL ATTENTION:In the event I cannot be reached to make arrangements for emergency medical care, I authorize the person in charge to take my child to:Name of Physician: Address: Ph.#:

Name of Emergency Medical Care Facility: Address: Ph.#:

I give consent for the facility to secure any and allnecessary emergency medical care for my child.

Signature - Parent or Legal Guardian

List any special problems that your child may have, such as allergies, existing illness, previous serious illness, injuries and hospitalizations during the past 12 months, any medication prescribed for long-term continuous use, and any other information which caregiver’s should be aware of:

Child daycare operations are public accommodations under the Americans with Disabilities Act (ADA), Title III. If you believe that such an operation may be practicing discrimination in violation of Title III, you may call the ADA Information Line at (800) 514-0301 (voice) or (800)-514-0383 (TTY).

Texas Dept of Family and Protective Services

Form 2935Aug 2010 / Pg 2 of 3

ADMISSION INFORMATION

SCHOOL AGE CHILDREN:My child attends the following school:

CHECK ALL THAT APPLY:

Name of School and Address School Ph.#

His / her immunization record is on file at the school and all required immunizations and/or tuberculosis test are current. My child has permission to: walk to or from school or home,Vision and Hearing screening records are also on file. ride a bus, and/or be released to the care of his/her

sibling(s) under 18 years old.Name of sibling(s):

IMMUNIZATION RECORD:

I have provided the childcare operation with a copy of my child’s most current immunization record.

ADMISSION REQUIREMENT: If your child does not attend pre-kindergarten or school away from the child-care operation, one of the following must be presented when your child is admitted to the child-care operation or within one week of admission.Please check only one option:1. HEALTH-CARE PROFESSIONAL’S STATEMENT: I have examined the above named child within the past year and find that he / she is

able to take part in the day care program.

Health Care Professional's Signature Date2. A signed and dated copy of a health care professional’s statement is attached.

3. Medical diagnosis and treatment conflict with the tenets and practices of a recognized religious organization, which I adhere to or am a member of; I have attached a signed and dated affidavit stating this.

4. My child has been examined within the past year by a health care professional and is able to participate in the day care program.Within 12 months of admission, I will obtain a health care professional’s signed statement and will submit it to the child-care operation.

Name and address of health care professional:

Signature - Parent or Legal Guardian Date

VISION R 20/ L 20/ PASS FAIL

SIGNATURE DATE

HEARING 1000 Hz 2000 Hz 4000 HzPASS FAILR

L

SIGNATURE DATE

Signature – Parent or Legal Guardian Date

Signature – Parent or Legal Guardian Date

Texas Dept of Family and Protective Services

Form 2935Aug 2010 / Pg 3 of 3

ADMISSION INFORMATION

HEALTH REQUIREMENTS

Name of Child: Date of Birth:

Age ►Vaccine ▼ Birth 1 mos 2 mos 4 mos 6 mos 12 mos 15 mos 18 mos 19-23

Mos 2-3 Yrs 4-6 Yrs

Hepatitis B

Rotavirus

Diphtheria, Tetanus, Pertussis

Haemophilus influenzae type b

Pneumococccal

Inactivated Poliovirus

Influenza

Measles, Mumps, Rubella

Varicella

Hepatitis A

Meningococcal

TB TEST (if required) Positive Negative Date:

Signature or stamp of a physician or public health personnel verifying immunization information above.

Signature Date

Varicella (chickenpox) vaccine is not required if your child has had chickenpox disease. If your child has had chickenpox, please complete the

statement: My child had varicella disease (chickenpox) on or about (date) and does not need varicella vaccine.

Parent’s signature Date

I am excluding my child from the immunization requirements for reasons of conscience, including a religious belief. I have attached an official notarized affidavit form developed and issued by the Department of State Health Services. I understand this affidavit is valid for 2 years.

For additional information regarding immunizations contact the Department of State Health Services atwww. d s h s .s t a te.tx.us/immunize/publ i c .shtm