DARTMOUTH EARLY LEARNING CENTER
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__________________
BACKGROUND INFORMATION
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
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 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
Date
Finances/Tuition Policy
The cost for the primary program is $6650 for the 2010/2011 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(first and last) is due in installments May 15th and June 15th. Space is
limited and early registration is encouraged. An initial $125 registration fee is due upon enrolling. $100 will
be credited toward your first month's tuition. The second installment(last month tuition) is due by June 15th.
Tuition payments are due the last week of each month for the upcoming month. After a one week grace
period, a late fee of $10 per week will be assessed for tuition unpaid by the due date. No account may have
more than a one month balance at any time. 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 __________
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
Updated Initials Updated Initials
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
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
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
Updated Initials Updated Initials
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
Updated Initials Updated Initials
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.
LICENSING AUTHORITY
The Department Of Early Education and Care(EEC) is the licensing authority for the Dartmouth Early
Learning Center.