436 Port Reading Ave, Port Reading NJ 07064 |
(732) 634-1403
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Child/Parent/Guardian Information
Child's Name
First Name*
Middle Name
Last Name*
Birth Day
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Age
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Sex
Required*
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Male
Female
School
Required*
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Avenel Middle School
Matthew Jago School #28
Port Reading School #9
Pennsylvania Ave. School #27
Ross Street School #11
Not listed
Grade
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K
1
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Address
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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
Business Phone Number
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Maryland
Massachusetts
Michigan
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Mississippi
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Nebraska
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Ohio
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Rhode Island
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Tennessee
Texas
Utah
Vermont
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Washington
Washington D.C.
West Virginia
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Wyoming
None--International
Zip
Parent or Guardian Name - Dad
First Name*
Last Name*
Phone
Required*
-
-
ext
--select--
Home
Mobile
Work
Business 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
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
Are you currently enrolled in Child Care Solutions?
Select One
Yes
No
Photo Consent and Walking Trips Consent
Photo consent
Required*
Yes
No
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.
Consent and Liability Wavier for Walking trips
Required*
Yes
No
I grant permission for my child to participate in trips, walking, attended through the St. Anthony Study Hall/Summer Break Program. I understand that the walking routes include no safety hazards and that the walks will be near St. Anthony of Padua Church, such as Cypress Park and Spray Park and walks to and from the bus stop. I agree on behalf of myself, my child's other parent(s) and/or guardian(s), and my child named herein, to waive claim or claims that may be derived from any incident, accidents, or injury sustained resulting from participation in the trips during the enrolled programs and related activities. I further agree to indemnify, defend, and hold harmless: program sponsors St. Anthony of Padua Church and St. Anthony Study Hall Program; participating diocese, parishes, and schools; agencies and organizations working collaboratively with the program; all staff, volunteers, representatives, and adult supervisors of the afore mentioned institutions. I consent to the modes of transportation employed by the program staff and representatives.
Study Hall Rules
CHILDREN STUDY HALL FLOOR 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 doesn’t belong and keep your hands and any other body parts to yourself. 2) Must always stay in your group. 3) Children are only allowed to stay in the hall. 4) No electronics 5) Not allowed in kitchen, office, or storage area 6) No running in the hall 7) No sitting on tables or going under the tables. 8) No hand stands or tumbling on the floor. 9) No Ball play in the hall 10) No inappropriate language 11) Be kind to everyone – All the time. 12) 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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