Jack And Jill School 8316 Michael Road Richmond printable pdf download

Jack and Jill School

8316 Michael Road

Richmond, VA 23229

Mary C. Cox, Owner/Director

804-270-3030

2012-13 ALL DAY APPLICATION

Hours: 7:30 a.m. - 5:30 p.m. Tuition $180 week Registration/Activity Fee $100. (to be submitted with this application)

Arrival Time:________ Dismissal Time: _________

( ) Nursery

( ) Pre-Kindergarten

( ) Kindergarten

Parent’s Name: ____________________________ Address: ______________________________________________________________

Home Phone: ____________________ City: ______________________________________ State: _____ Zip Code: _________________

Child’s Name: _______________________ Nickname: ___________ Sex: ______ Age: _____ Birthdate:____________

Child’s Pediatrician: _______________________ Address: _______________________________________________ Phone: __________

Information on Child’s Physical Condition (Va. State Health Certificate MUST be submitted to Jack and Jill upon

enrollment):_____________________________________________________________________________________________________

Child’s Previous School Experience: _________________________________________________________________________________

What School Child Attended: ________________________________________________________________ Date: _________________

Fathers’ Occupation: ________________________ Name of Business: ______________________________________________________

Bus. Address: _________________________________________________________________________ Bus. Phone: ________________

E-mail: ___________________________________________________Cell Phone:_____________________________________________

Mother’s Occupation: ________________________ Name of Business: _____________________________________________________

Bus. Address: ________________________________________________________________________ Bus. Phone: _________________

E-mail: ___________________________________________________Cell Phone:_____________________________________________

List Three Credit References:

________________________________________________________________________________________________________________

Church Affiliation: ___________________________ Address: ____________________________________________________________

Minister’s Name: ________________________________________________ Phone: _________________________________

Name, address, relationship to child, and telephone number of two designated people we can call in case of emergency if the

parents cannot be reached: example, grandparent, aunt, etc. If one of these people cannot be contacted, we will try to contact the

other. These people should be outside of the immediate family.

Name: __________________________________Address:________________________________________________________________

Telephone #: ________________________________ Relationship to Child: __________________________________________________

Name: __________________________________ Address:________________________________________________________________

Telephone #: ______________________________ Relationship to Child: ____________________________________________________

AGREEMENTS:

1. The parent/guardian will give individual authorization for the child to participate in specific field trips, and agrees to keep the school up-to-date regarding any

changes in address, telephone numbers, persons to contact, medical problems of the child, etc.

2. The school agrees to notify the parent/guardian whenever this child becomes ill and the parent/guardian agrees to pick the child up as soon as possible after

being notified that the child is sick. In turn, Parent/Guardian agrees to notify the school within 24 hrs or the next business day after his/her child or any member of the

immediate household has developed a reportable communicable disease, as defined by the State Board of Health, except for life threatening diseases which must be reported

immediately.

3. The parent/guardian authorizes the school to obtain immediate medical care if any emergency occurs when he/she cannot be located immediately.

4. Jack and Jill reserves the right to dismiss a child with a week’s notice if the director determines that the child is not able to benefit from the school’s program.

5. Parent/guardian agrees to give this school’s director, 2 weeks written notice in advance of withdrawal of the child and agrees to make full payment for those

two weeks—even if the parent decides to take the child out of this school without having given such notice.

6. All fees are due on Monday of the current week. There is a $10 late fee charged for payments received after Monday. A $25 fee will be

charged the parent/guardian for any checks returned by the bank for any reason.

7. By signing below, the parent/guardian acknowledges and understands that this school is operated on a pre-determined budget, and that the

weekly fees must be paid to the school whether or not the child is in attendance. There is no waiver or deduction of fees caused by parent holiday, vacation,

the child’s illness, or any other reason.

8. An up-to-date health certificate for your child must be provided to this school upon application acceptance.

9. Tuition rates are effective as of June 1st annually.

10. Custody Papers shall be attached if parent is not allowed to pick up the child.

11. NOTE: Section 22:1-4.3 of the Code of VA states that unless a court order has been issued to the contrary, the non-custodial parent of a

student enrolled in a public school or day care center must be included, upon the request of such non-custodial parent, as an emergency contact for events

occurring during school or day care.

_____________________________________________________ Date: ________________

Parent’s/Guardian’s Signature

By signing the above, the parent/guardian acknowledges and understands that this school is operated on a pre-determined budget and the weekly fees must

be paid to the school whether or not the child is in attendance. . THERE IS NO WAIVER OR DEDUCTION OF FEES CAUSED BY PARENT

HOLIDAY, VACATION, THE CHILD’S ILLNESS, OR ANY OTHER REASON.

Name of person(s) or agency having legal custody of child: ________________________________________________________________

List person(s) authorized to pick up child:______________________________________________________________________________

List person’s NOT authorized to pick up child: _____

___________________________________________________________________________

(if additional space is needed, please use the back of this form and indicate that information is on the back)

IDENTITY VERIFICATION

(These Documents Must Be Shown to Jack and Jill’s Director)

Place of Birth _____________________ Birth Date_____________Birth Certificate Number _____________________ Date Issued _____________

Other Form of Proof _______________________________________________________________________________________________________

Term Registered: (Day) _______________ (Month) _______________ (Year) _______________

**$100 Registration/Activity Fee (Non-Refundable) MUST be attached to this form.

Jack And Jill School 8316 Michael Road Richmond

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