DARTMOUTH EARLY LEARNING CENTER
PRESCHOOL 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 / 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
Name of child’s physician ___________________________________ Tel. # ___________
Please indicate your child’s preferred schedule(Days/hours):
____________________________________________________________________
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 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. One of these eight
weeks will be applied to the very last week that your child is enrolled in the program. 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 OCCS 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. 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.