Student Registration Form

Child's Name *

First Name Middle Name Last Name

Date of Birth *

Date Date Picker Icon

Preferred Name

Image of Child *

Sex *

Female Male

Child's Home Language *

English Spanish

Child's Primary Address *

Street Address
Street Address Line 2
City	State
Zip Code	Country

County of Residence *

Legal Custody *

Both Parents [married] Legal Joint Custody [separated/divorced] Mother Only Father Only

Child Lives With *

Both Parents Mother Only Father Only

Individuals living in the home other than Parent/Guardian

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

Birth Certificate *

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Upload File

Parent Name *

First Name Last Name

Relation to child *

Mother Father Grandmother Grandfather Aunt Uncle Foster Parent

Address [if different than child]

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Employer *

Occupation *

Work Phone

Work Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Cell Phone *

Email *

example@example.com

Preferred Contact Method *

Work Cell Email

Parent Name

First Name Last Name

Relation to child

Mother Father Grandmother Grandfather Aunt Uncle Foster Parent

Address [if different than child]

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Employer

Occupation

Work Phone

Work Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Cell Phone

Email

example@example.com

Preferred Contact Method

Work Cell Email

Contact Name *

First Name Last Name

Relation to Child *

Relation to Parent *

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Work Number

Home Number

Cell Number *

Emergency Pick-Up *

Yes No

Contact Name

First Name Last Name

Relation to Child

Relation to Parent

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Work Number

Home Number

Cell Number

Emergency Pick-Up

Yes No

Contact Name

First Name Last Name

Relation to Child

Relation to Parent

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Work Number

Home Number

Cell Number

Emergency Pick-Up

Yes No

**If you need to add more emergency contact/pick-up persons, please contact the front desk.**

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
City	State / Province
Postal / Zip Code	Country

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

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?

Yes No

Regular Treatments

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

Does your child have a history of the following? *

Seziures Asthma Both of the above None 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 Easily G-Tube Heart Condition Shunt Skin Breakdown Tires Easily Tracheotomy

EQUIPMENT -Check all that apply

Glasses Hearing Aid Orthosis [AFO,SMO] Walker Wheelchair/Personal Stroller

Is your child potty-trained?

Yes No In 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.] *

Yes No

Parent/Guardian Signature *

Clear

Today's Date

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

Date

Immunization Form *

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Upload form

If the below questions do not apply to your child, please write 'none'.

Insurance Provider *

Policy Number *

Name of Policy Holder *

First Name Last Name

Policy Holder Date of Birth *

Date Date Picker Icon

Image of Front of Insurance Card *

Image of Back of Insurance Card *

Insurance Provider *

If no second insurance type n/a

Policy Number

Name of Policy Holder

First Name Last Name

Policy Holder Date of Birth

Date Date Picker Icon

Image of Front of Insurance Card

Image of Back of Insurance Card

New or Returning Student? *

Returning Student New Student

Number of Years at Apparo

Please indicate below your desired schedule. Actual schedule is based on availabiliy and will be determined at intake appointment. The school program is only offered at one rate, $640 per month, whether you choose to pick up early or to eliminate days. Unfortunately, our budget requires full tuition to operate with such low teacher to student ratios.

Early Arrival [7:00am - 8:30am] *

Monday Tuesday Wednesday Thursday Friday None

School Program [8:30am - 2:30pm] *

Monday Tuesday Wednesday Thursday Friday

Short Stay [8:30 - 12:30] (Only applies if in the under 3 class) *

Monday Tuesday Wednesday Thursday Friday not applicable

Extended Day [2:30pm - 5:00pm] *

Monday Tuesday Wednesday Thursday Friday None

After School Program (6-12 years old)[2:30pm - 5:00pm]

Monday Tuesday Wednesday Thursday Friday

Therapy Services at Apparo

OT PT ST

Home School District

Other Pertinent Documents

Browse Files

Current IEP, Therapy Assessments, Medical Documents

Financial Aid Application

Browse Files

Upload Completed Form from the Website

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 activities I 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

Date

Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Date	Postal Code

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