Barrington Academy

BARRINGTON ACADEMY

ENROLLMENT APPLICATION

Child's Name:

Date of Birth:

Enrollment Date:

Age:

Sex:

Social Security#

Address:

Classroom you are enrolling your child in

Infants	Toddlers	Two's	Three Year Old
GA Pre-K	Before School	After School	Before & After School

Father's Name:

Social Sec#

Address:

Home Phone:

Work Phone:

Employer's Name:

Employer address:

Mother's Name:

Social Sec#

Address:

Home Phone:

Work Phone:

Employer's Name:

Employer address:

Who does the child live with:

Mother

Father

Both

Other

Emergency Contact Person:(Other than Parents)

SSN#:

Address:

Home Phone:

Work Phone:

Child's Physician:

Phone #

Address:

Please list all persons approved to pick up your child (the child will not be released to any others without specific permission from the parents or guardians). Parents should arrange for emergencies.

Name:

Relationship to Child:

Address:

Home Phone:

Work Phone:

Parents of Guardian's Signature:

Witnessed By:

Date:

TUTION AGREEMENT

Your Child’s tuition amount is a weekly amount as defined on the Barrington Academy’s rate sheet. You will be informed of any changes in the tuition amount in advance.

Tution Payment Procedures

Your Child’s Tuition is to be paid in full on the Friday before the week your child is to attend the classroom. You are given a grace period of two days. If tuition is not paid in full by 6:15 P.M. on Tuesday of the week child is attending and there is a balance due to Barrington Academy, a late fee of $15.00 will be added to the tuition account. We will not be providing care for your child from Wednesday morning unless the tuition account is brought current. Parents may pay their child’s tuition on a monthly basis, if paid in the beginning of the month. The monthly tuition amount will be four or five times the weekly amount depending on the number of weeks in that month.

Return Check Charges

There will be a $25 charge for each check that is returned by the bank. After one returned checks we can only accept payment by cash, money order or cashier’s check for 30 days.

Vacation and Sickness Procedures

No vacations are allowed during the school year. In case of vacation, the tuition payment must be given before departure to avoid late fee and to hold the child’s place in your classroom. If your child is absent all week or present 1-2 days, the tuition fee due is as mentioned in the rate sheet a percentage of weekly tuition. Holidays do not count as absent days. In case of illness, the payment must be dropped off before Tuesday to avoid a late fee.

If you fail behind in your tuition payment, your child will not be permitted to come to the center unless the tuition account is brought current.

Termination Notice

A written notice must be turned in two weeks prior to withdrawing of your child. If we do not receive a written notification, you are required to pay the full two week fee. This fee is not the absentee fee, but full two week fee.

I have read the regulations regarding the Tuition Payment procedures and the tuition agreement and agree to abide by them.

Parent or Guardian Signature:		Date:
Parent or Guardian Signature:		Date:
Barrington Academy Director / Administrator:		Date:

VEHICLE EMERGENCY MEDICAL INFORMATION & CONSENT FOR TREATMENT

Child's Name:

Date of Birth:

Sex:

Address:

Father’s Name:

Cell Phone #:

Home Phone:

Work Phone:

Mother’s Name:

Cell Phone #:

Home Phone:

Work Phone:

Emergency Contact Person: (Other than Parents )

Phone #:

Child’s Physician:

Phone #

Address:

Medical Facility the Center uses is Henry Medical Center

Address : 1133 Eagles Landing Parkway Stockbridge , GA

Child’s Allergies

Current Prescribed medication

Child’s special medical needs and conditions

Date of last Tetanus

In the event a child in the center is hurt or injured, it is recommended that the paramedics to be contacted immediately. The paramedics will decide whether they can administer the treatment at the center or whether the child should be taken to the nearest hospital for emergency care. Once the child is in the hospital, the child’s parent(s) will be contacted. The parent(s) will be asked to meet a representative from Barrington Academy at the hospital. If the parent(s) cannot be reached, most hospitals will not treat a child, regardless of how serious the injury. This form authorizes Barrington Academy’s representative to act on behalf of the parent(s) by requesting that the hospital staff treat the child.This is to certify that in the event of an emergency involving my child and if Barrington Academy cannot get in touch with me, I hereby authorize any needed emergency medical care. This is to certify that for the period my child is enrolled at Barrington Academy, I hereby constitute and appoint Barrington Academy as my true and lawful attorney, for the purpose of authorizing release of medical information, medical treatment to , and performance of any procedure determined to be necessary after consultation with the Emergency or Family Physician , on my child. I further agree to be fully responsible for all medical expenses incurred during the treatment of my child.I also agree not to hold Barrington Academy legally responsible for any injuries that might occur while the child is in the center.

Signature of Parent / Guardian

Witnessed By

Date

Pre School Child’s details

Child’s Last Name

First Name

Birthday

Day

Month

Year

Please list all of your child's allergies

Food
Insects
Medications
Other

Toilet Habits

Can the child be relied upon to indicate his/her bathroom wishes?

Yes

No

Does your child have frequent toilet accidents?

Yes

No

How does your child reacts to them

Sleeping Habits

What time does your child go to bed?

Awaken

What is the child's mood on awakening?

What is your child's nap schedule:

Social Behavior

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