Main Registration

Child/Parent/Guardian Information

Child's Name

First Name*

Middle Name

Last Name*

Birth Day

Required* //

Age

Required*

School

Required*

Grade

Required*

Address

Street 1*

Street 2

City*

State*

Zip*

E-mail

Required*

This is required because this is our primary form of communication when not in session.

Parent or Guardian Name - Mom

First Name*

Last Name*

Phone

Required* -- ext

Employer Phone Number

Street 1

Street 2

City

State

Zip

Parent or Guardian Name - Dad

First Name*

Last Name*

Phone

Required* -- ext

Employer Phone Number

Street 1

Street 2

City

State

Zip

Emergency Contacts

Emergencies may necessitate contact with designated individuals who can assume responsibility for the welfare of your child when you are available. Please review this form and carefully choose people who you feel should be called in an extreme emergency when you cannot be reached. You must provide the names and phone numbers of three people. It is imperative that your selection is based on several criteria: 1. Be sure that individuals are in close proximity to the Study Hall and are responsible individuals who your child trusts. 2. Notify these individuals that you have designated them to serve in this capacity on this form. For our program, please provide three (3) names and full addresses other than parents/guardians:

Contact 1

First Name*

Last Name*

Contact 1 Phone

Required* -- ext

Contact 2

First Name*

Last Name*

Contact 2 Phone

Required* -- ext

Contact 3

First Name

Last Name

Contact 3 Phone

-- ext

Medical Information

Please provide information on Hospital choice, allergies, any physical limitations and Doctor information

Hospital Choices

Please provide 2 choices*

Consent and Agreement for Emergencies
Required*

Checking yes to this As parent/guardian, I give consent to have my child, receive first aid by the child care staff, and if necessary be transported to receive emergency care.*

Checking indicates consent

I also authorize the Director or Director Designee to contact my child’s health care provider to alert him/her to my child’s situation. I understand that I will be responsible for all charges not covered by insurance. I give consent for the emergency contact person listed on Emergency Form Part I to act on my behalf until I am available. I agree to review and update this information whenever a change occurs and at least every six (6) months.

Allergy/Medical Information

Please describe any medical information that might be useful to the staff in dealing with your child. List below. If none write none.*

Food, Drug, Beverages, Insects and Vegetation.

Seizure Action Plan
Required*

	Seizures Yes
	Seizures No

Does your child have seizures? If so please fill out Seizure Action Plan https://saintanthonypadua.org/media/1/18/SeizureActionPlan.pdf

Activities

Please List any physical limitations, Activity preferences and any special needs*

Doctor Name

First Name

Last Name

Doctor Address

Street 1

Street 2

City

State

Zip

Insurance Carrier and Policy #

List any information (special needs/IEP) that may be pertinent in caring for your child: (If Yes, additional form need to be completed)

Do you need a Tuition Payment Plan

Select one

	Yes
	No

Policies and Agreements

OUR POLICY ACKNOWLEDGEMENT As enrolled parents, it is our obligation to inform you of the following policies set forth by the St. Anthony Study Hall Program. To understand the policies, we set please click on link Policies. By clicking the "Yes", I understand that all policies set forth by the daycare are available for me to always review. The Policies are Information to Parents, Rules and regulations policy, Release policy, Expulsion policy, Communicable disease policy, Technology and social media policy, Medication administration policy, Disruptive behavior policy, Homework policy, and Late pick up policy. To see the policies, go to our website https://www.saintanthonypadua.org/66.

Acknowledgement Document

https://www.saintanthonypadua.org/media/1/18/Policy%20Acknowledgements.pdf

Policy Acknowledgement
Required*

Please check "Yes" or "No"*

	Yes
	No

Subsidized Families Only

To all parents and guardians who utilize the Child Care Solution Program or Work First New Jersey program the following are the contractual and Study Hall policies you are required to abide by. Failure to comply could cause an early termination of your contract services with the St Anthony Study Hall program. • You are required to swipe in and out every day as per Part E – Parent Certification of your contract, you cannot go more than 3 days behind. We will terminate without notice if you do. • You can get an extra card to give to someone else who picks your child up to swipe for you. The swiping takes less than a minute to do, but when you are behind it takes much longer. When you are doing your catch up and someone else must swipe, you can cause them to be delayed as well. • As per Part E – Parent Certification of your contract you are required to pay all copay and fees. These are required to be paid by the end of the previous month. Payment arrangements are available and must be filled out each month as needed. Failure to pay on time will result in immediate termination and a $25.00 late fee. The Study Hall does not get paid if you do not swipe. In the event you miss a day, you will be charge the full rate for the day ($25.00 for school year and $50.00 for any full day).

Select One

	Yes
	No

Photo Consent

As parent/guardian, I understand that archival and promotional media (pictures, video, audio, etc.) will be taken during this event. I give permission for my son/daughter's image and/or other appropriate media content to be used for promotional materials (brochures, newsletters, web page, calendars, Power Points, etc.) in promoting St. Anthony Study Hall and/or Summer Break Programs.

Select One
Required*

	Yes
	No

Study Hall Rules

The following is a list of rules we use while children are in our facility: Please review these rules with your child and be sure that they understand them. 1) DO NOT put your hands, feet or anything else where it does not belong and keep your hands and any other body parts to yourself. 2) Please keep a 6 feet social distance. 3) Must always wear face mask. 4) Children are only allowed to stay in the hall itself. 5) No electronics are to be used unless for schoolwork. 6) Not allowed in kitchen, office, or storage area. 7) All bags will be thoroughly searched for homework and computers for assignments. 8) All homework must be completed before having time to play or a notice will be sent home. 9) No running in the hall. 10) No sitting on tables or going under the tables. 11) No hand stands or tumbling on the floor. 12) No ball play in the study hall. 13) No inappropriate language 14) Be kind to everyone – All the time. 15) MOST IMPORTANT – HAVE FUN!!!!! *Phone calls can be made with office phone or children can go to staff and use their phone in our office.

Select One
Required*

Yes

Spam Capture

Office Use Only

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Main Registration

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