436 Port Reading Ave, Port Reading NJ 07064 |
(732) 634-1403
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Main Registration
Child/Parent/Guardian Information
Child's Name
First Name*
Middle Name
Last Name*
Birth Day
Required*
Month
January
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April
May
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Day
1
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Age
Required*
Sex
Required*
Please make a selection
Male
Female
School
Required*
Please make a selection
Avenel Middle School
Matthew Jago School #28
Port Reading School #9
Pennsylvania Ave. School #27
Ross Street School #11
Not listed
Grade
Required*
Please make a selection
K
1
2
3
4
5
6
7
8
Address
Street 1*
Street 2
City*
State*
-- select --
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Washington
Washington D.C.
West Virginia
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None--International
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
--select--
Home
Mobile
Work
Employer Phone Number
Street 1
Street 2
City
State
-- select --
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
Washington D.C.
West Virginia
Wisconsin
Wyoming
None--International
Zip
Parent or Guardian Name - Dad
First Name*
Last Name*
Phone
Required*
-
-
ext
--select--
Home
Mobile
Work
Employer Phone Number
Street 1
Street 2
City
State
-- select --
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
Washington D.C.
West Virginia
Wisconsin
Wyoming
None--International
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
--select--
Home
Mobile
Work
Contact 2
First Name*
Last Name*
Contact 2 Phone
Required*
-
-
ext
--select--
Home
Mobile
Work
Contact 3
First Name
Last Name
Contact 3 Phone
-
-
ext
--select--
Home
Mobile
Work
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
-- select --
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
Washington D.C.
West Virginia
Wisconsin
Wyoming
None--International
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
Child Custody Agreement
Required*
Please make a selection
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
No
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