Student Registration Form

Early Education and Intervention Program

APPLICATION
Child's Info
Child's Name *

First NameMiddle NameLast Name
Date of Birth *

MonthDayYear
Date
Preferred Name
Birth Certificate*

Browse Files
Upload File Cancelof
Image of Child*
Gender*

FemaleMale
Child's Home Language*

EnglishSpanishOther
Child's Primary Address *

Street Address

Street Address Line 2

CityState

Zip Code
County of Residence *
County of Residence*
Legal Custody*

Both Parents [married]Legal Joint Custody [separated/divorced]Mother OnlyFather OnlyOther
Child Lives With*

Both ParentsMother OnlyFather OnlyOther

Individuals living in the home other than Parent/Guardian

	Name	Age	Relationship to Child
Person 1
Person 2
Person 3
Person 4

Is this child currently enrolled in another early childhood learning center or school?*

YesNo
Name of Facility
If none, type n/a.
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Has this child been unenrolled or asked to leave another early childhood learning center or school*

YesNo
Name of Facility
If none, type n/a.
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I understand that it is in the best interest of my child and Apparo Academy that the admissions and teaching staff have the most accurate information about my child to help make a successful transition to Apparo. By signing below, I am consenting to the Principal, Nurse, and/or Director of Operations from Apparo Academy to contact our prior school (s) to obtain information about my child and their school day.
Parent/Guardian Signature*

Clear
Today's Date

MonthDayYear
Date
Parent/Guardian 1
Parent Name *

First NameLast Name
Relation to child*

MotherFatherGrandmotherGrandfatherAuntUncleFoster ParentOther
Address [if different than child]

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer *
Occupation *
Work Phone
Work Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone *
Email *
example@example.com
Preferred Contact Method*

WorkCellEmail
Parent/Guardian 2
Parent Name

First NameLast Name
Relation to child

MotherFatherGrandmotherGrandfatherAuntUncleFoster ParentOther
Address [if different than child]

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer
Occupation
Work Phone
Work Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone
Email
example@example.com
Preferred Contact Method

WorkCellEmail
Emergency Contacts & Authorized Pick-Ups
Contact Name*

First NameLast Name
Relation to Child*
Relation to Parent*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Work Number
Home Number
Cell Number*
Emergency Pick-Up*

YesNo
Contact Name

First NameLast Name
Relation to Child
Relation to Parent
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Work Number
Home Number
Cell Number
Emergency Pick-Up

YesNo
Contact Name

First NameLast Name
Relation to Child
Relation to Parent
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Work Number
Home Number
Cell Number
Emergency Pick-Up

YesNo
**If you need to add more emergency contact/pick-up persons, please contact the front desk.**
Emergency Medical Information & Authorizations
If the below questions do not apply to your child, please write 'none'.
Child's Pediatrician*
Pediatrician's Phone Number*
Pediatrician's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Other Physicians or Specialists

	Name of Physician	Speciality	Phone Number
Physician 1
Physician 2
Physician 3
Physician 4

List any Accidents/ Major Illnesses/ Operations*

	Date	Age	Circumstance
1
2
3
4

Child's Diagnosis and/or Medical Conditions*

Child's Current Development*

	Advanced	Within Normal Limits	Somewhat Delayed	Significantly Delayed
Communication/Language
Fine Motor
Gross Motor
Hearing
Self-help [feeding,dressing]
Social/Emotional
Vision

Notes about Child's Current Development

Therapy Services Currently Receiving or Awaiting (if none type n/a)*

	Therapy Facility	Therapist	Frequency
Speech Therapy
Feeding Therapy
Occupational Therapy
Physical Therapy

Medications [type none if not applicable] *

	Medication Name	Dose	Frequency
Medication 1
Medication 2
Medication 3
Medication 4

Will medication be given during school hours?

YesNo

Regular Treatments

	Frequency
Blood Sugar Monitor
Breathing Treatment
Catheterization
Oxygen Monitor
Tube Feed
Other

Does your child have a history of the following?*

SeziuresAsthmaBoth of the aboveNone of the above
If yes to the above question, does your child take emergency medicine? [List all]

Allergies*

	Type of Allergy [ex. Peanut]	Reaction	Emergency Medication
Allergy 1
Allergy 2
Allergy 3

RISKS - Check all that apply

Chokes EasilyG-TubeHeart ConditionShuntSkin BreakdownTires EasilyTracheotomyOther
EQUIPMENT -Check all that apply

GlassesHearing AidOrthosis [AFO,SMO]WalkerWheelchair/Personal StrollerOther
Is your child potty-trained?

YesNoIn Progress
Except for first aid, personnel shall not dispense prescription or non-prescription medications to a child without specific written authorization from the child's physician or parent. Such authorization will include, when applicable, date; full name of the child; name of the medication; prescription number, if any; dosage; the dates to be given; the time of day to be dispensed; and signature of parent. I give Apparo Staff permission to apply one or more of the following topical ointments/preparations to my child in accordance with the directions on the label of the container. [Baby Wipes, Cortizone 10 Cream, Latex Free Band Aids, Neosporin or Triple Antibiotic Ointment, Non-prescription Ointment [A&D, Vaseline, Aquaphor] and Sting Relief.]*

YesNo
Parent/Guardian Signature*

Clear
Today's Date

MonthDayYear
Date
Should my child suffer an injury or illness while in the care of Apparo and if I am unable to be reached immediately, I authorize the facility to secure such medical attention and care as necessary. Additionally, I authorize the transfer of health records to emergency care providers. I shall assume responsibility for payment for services.*

Yes, I have read and authorize the above statement.
Parent/Guardian Signature*

Clear
Today's Date

MonthDayYear
Date
Is your child up-to-date on all required immunizations? You will be required to submit a state immunization form upon acceptance.*

YesNoIn Process
Health Insurance Information
If the below questions do not apply to your child, please write 'none'.
Insurance Provider*
Policy Number*
Name of Policy Holder*

First NameLast Name
Policy Holder Date of Birth*

MonthDayYear
Date
Health Insurance Information

Secondary Insurance
Insurance Provider*
If no second insurance type n/a
Policy Number*
Name of Policy Holder

First NameLast Name
Policy Holder Date of Birth

MonthDayYear
Date
Enrollment Info
Therapy Services Needed

OTPTST
Home School District
Apparo Academy is open from 7:30 - 4:00, Monday through Friday. The tuition includes that entire time and you may drop off or pick up anytime during those hours. However, please be aware that the primary educational school hours are from 8:30 - 12:30 and then naps. We appreciate you making every attempt to have your child on time for instruction.

Tuition for children who have not turned one prior to September 1st, and for our oldest class of children over 5 (Transitional Kindergarten) is $1025 per month.

Tuition for all other children is $950 per month.
Other Pertinent Documents

Browse Files
Current IEP, Therapy Assessments, Medical Documents Cancelof
Financial Aid Application

Browse Files
Upload Completed Form from the Website Cancelof
Parental Authorizations
Apparo utilizes an electronic communication tool to increase parent engagement. This program will allow our teachers to capture special moments, take photos, and videos of the children in action as well as send you classroom information directly to your phone/email. We consider all information captured using a digital media to be a private communication between our school and our families. No personal information is shared with any external parties and as a parent you will only receive information specifically about your child.
I give permission for my child’s daily notes and photos to be sent to me electronically. I understand that I will not receive paper copies of these documents.I refuse permission for my child’s daily notes to be sent only via email and would like to receive a hard copy document.
Use of Child Information, Photo or Video Image for Community Awareness, Educational Purposes, Apparo Website, and Public Relations. Apparo Academy may use the images and/or information of students to increase community awareness and educate the community on the services and programs at Apparo. We may use a child’s first name and the personal characteristics that identify or describe the child and if applicable, the impact of his/her developmental delay or disability during agency tours, community exhibits and presentations. Apparo Academy has a website, www.apparoacademy.org. The site displays a variety of pictures that include children, staff, volunteers, and parents participating in daily programs, center events and agency fund raising events. Additionally, Apparo has other social medial platforms such as Facebook and Instagram that may include a child’s image.
I give permission to take pictures or videos of my child to be used to increase community awareness and educate the community on the services and programs of Apparo Academy. These pictures may be placed on the Apparo website and/or other social media platforms. Also, I give permission for Apparo to use my child’s first name and the personal characteristics that identify or describe the child and if applicable, the impact of his/her developmental delay or disability in community exhibits and presentations.I refuse permission for use of pictures or videos of my child for community awareness and marketing as well as the use of mychild’s information during tours, exhibits, presentation and/or any other form of marketing or public relations.
Each child receives a developmental assessment and ongoing tracking of student performance using the GELDS standards. Apparo uses a variety of assessment tools including the standardized Ages and Stages Questionnaire. The child’s classroom teacher can access the expertise of licensed speech pathologists, occupational and physical therapists. Our developmental assessments are not a medical checkup and do not determine IQ scores. It will guide us on whether your child is functioning within normal limits compared to other children of the same age, and help us plan activities based on your child’s strengths and weaknesses and unique characteristics.
I give my permission for my child to receive a developmental screening by the staff in order to track developmental progress. I understand that I will receive a copy of the screening results and periodic progress updates.I refuse permission for my child to receive a developmental screening by the staff. I understand that my child will not receive specific classroom goals and will not receive progress updates.
This permission is granted to view and use the records for the purpose of providing service, transitioning service and coordinating service. Records are also used to instruct the university students placed on our campus for field experience and internships. Apparo's professional team is automatically granted access to carry out their duties on behalf of the children and families. Agency staff complies with Health Insurance Portability and Accountability Act of 1996, HIPAA.
I give permission for local school system staff and/or college and university students/interns to view records for purposes described above.I refuse permission for any other than Apparo staff to view my child’s records.
Apparo Academy routinely includes Pet Therapy in the monthly schedule of activities, in partnership with community volunteers. Community organizations may bring animals to center activities for purposes such as, but not limited to, environmental education, unit themes related to farm animals, petting zoos, etc. Apparo Academy uses the rules of our licensing authority, Bright from the Start, when including animals in program activities.
I give my permission for my child to participate in Pet Therapy and other curricular activities or center events that may include animals.I refuse permission for my child to participate in Pet Therapy and other curricular activities or center events that may include animals.
Curriculum activities or center events may include water-related activities. Water related activities at Apparo have depth maximums of 2 inches for infants, 6 inches for toddlers and 12 inches (1 Ft) for preschoolers. Apparo uses the rules of our licensing authority, Bright from the Start, when conducting water-related activities.
I give my permission for my child to participate in water-related activitiesI refuse permission for my child to participate in water-related activities.
PARENT ACKNOWLEDGEMENTS*

I, as the custodial parent/guardian of the child enrolling in Apparo’s Early Education and Intervention Program, have read, understand and will abide by the policies and procedures that are included in both the Parental Agreement and Apparo Parent Handbook throughout the duration of said child’s enrollment in the program.I, as the custodial parent/guardian of the child enrolling in Apparo's Early Education and Intervention Program, have been offered, read and understand the Notice of Privacy Practices.
Parent/Guardian Signature*

Clear
Today's Date

MonthDayYear
Date

Early Education and Intervention Program

Child's Info

Parent/Guardian 1

Parent/Guardian 2

Emergency Contacts & Authorized Pick-Ups

Emergency Medical Information & Authorizations

Health Insurance Information

Health Insurance Information

Enrollment Info

Parental Authorizations

Demographics

Survey

Payment Methods