STUDENT INFORMATIONAUTHORIZATIONSSTUDENT INFORMATIONFirst Name *Last Name *Date of Birth *Sex *FemaleMaleHome Adress *City *State *Zip Code *Email *Email Address(es) where you wish to receive school correspondence*Parent/Guardian 1 Full Name *List where parent/guardian may be reached while child is at school. Write “home” for non-‐working parent or parent working from home.Place of Work *Cell Phone *Parent/Guardian 2 Full Name *List where parent/guardian may be reached while child is at school. Write “home” for non-‐working parent or parent working from home.Place of Work *Cell Phone *Emergency ContactPerson to call in case of an emergency if parents cannot be reached. The emergency contact must have a local address.Emergency Contact *Relationship *Phone No. *Full Address ( Street Name, Street No. and City) *DAYS AND TIMES I WISH TO ENROLL MY CHILDSchool regular hours are 9:00am to 1:00pm Tuesday and Thursday Monday, Wednesday, and FridayMonday – FridayAdd Early Drop off -‐ 8:00am **Add Stay and Play -‐ 2:00pm pick up ****Available only for children 3 and up. I hereby authorize Northwest Spanish School to allow my child to leave the childcare operation ONLY with the following persons. Please list name and telephone number for each. Children will only be release to a parent/guardian or a person designated by the parent/guardian after verification of ID.Name 1 Name 2 Name 3 Phone No. 1 Phone No. 2 Phone No. 3 MEALSMEALS *I understand that the following meals, provided by me, will be served to my child while in care: AM Snack and LunchI have read the school policies regarding meals and I I have knowledge of those foods and drinks not allowed in the school.RECEIPT OF WRITTEN OPERATIONAL POLICIES I acknowledge receipt of the NWSS Operational Policies and Discipline and Guidance Policies. I have read each section completely and agree to abide by all policies and procedures of Northwest Spanish School. I also understand that late fees will apply for late tuition payments and late student pick up, as established on our school operational policies.Parent Name *ADMISSION REQUIREMENTSI understand that a copy of the following documents must be presented prior to admission into the school.Updated copy of child’s immunization records *A signed copy of a health care professional statement, stating that she/he has examined the above name child within the past 12 months and finds that she/he is able to participate in the preschool program. (Download Health Statement Form) *Vision and hearing screening results (for children 4 years and older)MEDICAL INFORMATIONIn the event I cannot be reached to make arrangements for emergency medical care, I authorize the operation’s employees to take my child to (you must provide information for both, a primary care provider and a hospital or emergency center within your insurance network):Child’s Primary Care Provider *Name of Physician Address *Phone No. *Hospital or Emergency Medical Care Name of Hospital or Emergency Medical Care Facility: *Address *Phone No. *I give consent for the facility to secure any and all necessary emergency medical care for my child.MEDICAL CONDITIONS AND ALLERGIESPlease respond yes or no to the conditions below regarding your child. If yes, please describe. If your child has a food allergy, a copy of the food allergy plan completed by her/his doctor is required.Food allergies or severe allergies NoYesPlease describe Existing illness NoYesPlease describe Previous serious illness NoYesPlease describe Serious injuries or hospitalization in the past 12 months NoYesPlease describe Medication prescribed for long-‐term continuous use NoYesPlease describe Any other condition which we should be aware of NoYesPlease describe Please read each statement below. Sign each statement so we can acknowledge your approval.SPLASH DAY *I authorize My child to participate in supervised water activities during our splash day while in the care of Northwest Spanish School. These activities may include, but are not limited to, wading pools, splash play, sprinkler play, and or water table activities.PHOTOS AND VIDEO *I authorize Northwest Spanish School to photograph and videotape my child for school purposes. I authorize NWSS to share theses photos on our classroom online gallery, post them on bulleting boards, and on our website or Facebook page. To protect student privacy, names of the students are never included.TUITION AGREEMENTI hereby authorize Northwest Spanish Immersion School, LLC to initiate debit entries for the 2021-‐2022 school year for the student listed above. A one-‐time debit for the supply fee will occur on June 15, 2021, followed by 10 tuition installments occurring on the 15th day of each month, beginning on August 15, 2021 and ending on May 15, 2022. The amount debited will depend on the number of days and hours enrolled in the preschool program. If you are completing enrollment after June 15, 2021, the supply fee will be charge to your account after enrollment. *Please debit my checking account indicated below at the depositary financial institution named below. This authorization to remain in full force until Nortwest Spanish School, LLC has received written notification from me of its termination at least 30 days prior to the next debit scheduled.Depository Name (Financial Institution): *Routing Number: *Account Number: *Depository Name (Name on the Account): *Signature – Parent or Legal Guardian * Today’ Date *Answer to prove you are human. * = Enrollment Fee *Price: $ 105.00NWSS is a public accommodation under the Americans with Disabilities Act (ADA), Title III. If you believe that NWSS may be practicing discrimination call the Information Line at (800) 514-0301 (voice) or (800)-514-0383 (TTY).PhonePreviousNextSubmit and Pay
