APPLICATION FOR
ADMISSION
Please print and fill out all blanks ( use
NONE or N/A if not applicable)
Child’s Full Legal Name
______________________________________________________
Street
Address
_______________________________________________________________
City
____________________________ State ____________ Zip Code _____________
Home Phone ___________________________ SS#
______________________________
Subdivision
_________________________________________________________________
STUDENT BIOGRAPHICAL
INFORMATION
Date of
Birth ______________
Age __________
Citizenship
__________________
Place of
birth
________________________________________________________________
City
State
Country
Religious Preference
___________________________________________________________
Ethnic
Background:
_____ Asian or Pacific
Islander
_____ American Indian/Alaskan
Native
_____ Black/African
American
_____
White/Anglo/Caucasian
_____ Other. Please specify
___________________________________________________
Sex:
_____ Male
_____
Female
PARENTS /
GUARDIANS
Father:
Mother:
_____ Mr. _____ Dr.
_____ Mrs. _____ Dr. _____ Ms.
Name _________________________________ Name
___________________________
Occupation ___________________________
Occupation
______________________
Title ________________________________
Title
____________________________
Employer _____________________________
Employer
________________________
Address ______________________________
Address
__________________________
City, State, Zip _____________________
City, State, Zip
____________________
Work number(s) ______________________
Work number(s)
__________________
Cell Number(s) _______________________
Cell Number(s)
____________________
Work Hours ___________________________ Work
Hours
______________________
E-mail address ______________________
E-mail address
____________________
Address (if different from
applicant’s)
___________________________________________
Parents:
_____ Married
_____ Divorced
_____
Separated
Describe the general health
of parents____________________________________________
Are there any limitations on
either parent’s right to pick up or visit the child at
school?
_____ Yes _____ No
If yes, please attach a copy of the court order to
keep on file at IQ Academy.
Please explain any social or
family circumstances of which IQ Academy should be
aware:
HEALTH
INFORMATION
Please submit immunization form 3231 – required by Georgia
Updated forms are required
as they expire
Physician
__________________________________________________________________
Practice
____________________________________________________________________
Address
____________________________________________________________________
City, State, Zip
______________________________________________________________
Phone Number
______________________________________________________________
Brief
Health History
__________________________________________________________
Social/Emotional
Concerns_____________________________________________________
___________________________________________________________________________________________
ALLERGIES
List all allergies or
sensitivities to drug, food, etc. and reaction. Please write none if no allergies
exist. All food allergies require written
documentation from a physician.
____________________________________________________________________________________________
**For each allergy listed that may require medication, an Allergy Action Form must be completed.
MEDICATION
State Law requires that all medication taken at school must be turned in to the office with the complete medication form to administer
List all medications
currently being taken on a regular basis:
____________________________________________________________________________
Any medical conditions or
special needs (i.e.: Asthma, RAD, Reflux, food intolerance or religious food
preferences) of which the school should be aware? _____ Yes _____ No
If yes, please explain
___________________________________________________________________________
List symptoms:
_______________________________________________________________
____________________________________________________________________________
List food(s) to be omitted
from diet____________________________________________
PreK3 & up: Is your
child potty-trained? _____ Yes _____
No
If no, please give
details
_______________________________________________________
____________________________________________________________________________
EMERGENCY AND RELEASE
INFORMATION
Other persons to whom IQ Academy is
authorized to release this child shall be listed below. Under no circumstances will IQ Academy
release this child to anyone not identified below without specific instructions
from the parent. Special
instruction forms are available at the front desk. IQ Academy will not allow a child to
enter or leave without an adult escort (18 years or older.) Additions or changes to this list must
be made in writing.
EMERGENCY
1. Name _________________________________ Relationship
______________________
Address
____________________________________________________________________
Phone Number(s)
____________________________________________________________
2. Name _________________________________ Relationship
______________________
Address
____________________________________________________________________
Phone
Number(s)
____________________________________________________________
RELEASE
AUTHORIZATION
1. Name _________________________________ Relationship
______________________
Address
____________________________________________________________________
Phone Number(s)
____________________________________________________________
2. Name _________________________________ Relationship
______________________
Address
____________________________________________________________________
Phone Number(s)
____________________________________________________________
GRANDPARENTS
MATERNAL
Full
Name
__________________________________________________________________
Address
____________________________________________________________________
City _________________________ State
______________
Zip
__________________
Phone Number(s) ______________________ Email
address
________________________
Business Name
______________________________________________________________
Business Address
____________________________________________________________
City _________________________ State
_________________
Zip
__________________
PATERNAL
Full
Name
__________________________________________________________________
Address
____________________________________________________________________
City _________________________ State
______________
Zip
__________________
Phone
Number(s)__________________Email address
______________________________
Business Name
______________________________________________________________
Business Address
____________________________________________________________
City _________________________ State
_________________
Zip
__________________
PREVIOUS SCHOOLS
Please list all previous school
attended. All records must be received prior to
admission.
School Name
Dates of attendance
Reason for leaving
School Name
Dates of attendance
Reason for leaving
School Name
Dates of attendance
Reason for leaving
SIBLINGS
Please list the name(s) of
all siblings and any schools attended (preschool –
college)
Sibling Name
School Attended Dates
of Attendance
Reason for leaving
Sibling Name
School Attended Dates
of Attendance
Reason for leaving
Sibling Name
School Attended Dates
of Attendance
Reason for leaving
FINANCIAL AND PROCEDURAL
AGREEMENT
FEES AND TUITION
An initial registration fee of Two
hundred dollars ($200.00) shall be
paid for each child at the time of enrollment, renewed each year
thereafter. . All fees are non-refundable. No bills or invoices are
sent.
A fee of fifteen dollars
($15.00) or one dollar ($1.00) per minute, whichever is greater, will be
assessed for each child not picked up at the end of the school
program.
LATE CHARGES AND
PENALTIES
Monthly tuition is due by
the first of every month.
A late charge of twenty five ($25.00) dollars shall be automatically
added when a balance is carried forward.
If an account becomes delinquent (over one week past due without receipt
of payment) there will be an additional weekly service charge of five per cent
(5%) of the past due balance added automatically. In the event arrangements to
make payment are not made, IQ Academy may, at its discretion, dismiss the child
and the parent shall remain responsible for the balance due and any expenses
incurred by IQ Academy in the pursuit of payment.
ADMISSIONS
Initial
and continued enrollment will be at the discretion of IQ Academy based upon the
best interests of the child, the expectation that he/she will benefit from the
program, and the health, safety and general welfare of the child and the other
enrolled children. Enrollment shall be for children two and half years through
five and half years of age without regard to race, creed, sex, or national
origin.
CURRENT
INFORMATION
The
parent is required by state law to update information on the enrollment
application as necessary. Please remember when any of your phone numbers or your
address change, updates must be made immediately in
writing.
PARENT HANDBOOK
Each
parent is responsible for reading the IQ Academy Parent Handbook. Signature on this application
acknowledges receipt of, understanding of, and adherence to all policies stated
in the Parent Handbook and any addendum (which may be in the form of a
memo.)
GENERAL AND FINANCIAL
ACKNOWLEDGMENTS
To the best
of our knowledge the information contained in this application is true and
accurate. The administration may
verify any part of this application material. If any part of this application is
inaccurate, or the provisions not upheld, the student is subject to withdrawal
from the school.
We have specifically
reviewed each of the provisions of this application and Parent Handbook and
hereby agree to comply with all provisions hereof.
As parents/guardians of the
applicant, we attest that the information above is true and accurate to the best
of our knowledge. If the applicant is accepted at IQ Academy, we grant the
school officials the permission to secure medical attention as needed in case of
emergency. By signing this application we agree to enroll our child for the
following term and program.
Start date:
___________
All Day
Monday – Friday 7:30 – 5:30 Tuition :
$820.00
Full Day
Monday – Friday 8:30 – 3:30 Tuition: $690.00
Half Day
Monday – Friday 8:30 – 12:30
Tuition:
$560.00
Early Bird
Monday – Friday
7:30 – 8:30
Tuition:
$40.00
After-school
Monday –
Friday 3:30 – 5:30
Tuition:
$80.00
The only acceptable causes
of termination of this agreement will be with 30 days notice or there will be a
penalty equivalent to one month of the child’s
tuition.
I would like to pay: __ Full (5% discount) __
Semi-annually __
Quarterly __
Monthly.
_____ Please check if you would
like a receipt after each payment
Please check the method of
payment:
__Check __Credit Card
Card Number
___________________________________Exp. Date
________Code:_______
Please state any special
suggestions/instructions you have in regards to your child while he/she is in
our care:
____________________________________________________________________________
____________________________________________________________________________
___________________________________
__________________________________
Parent’s signature
Date
Parent’s signature
Date
For teachers only. ( Parents please do not write in this
area) Notes /
comments:
_______________________________________________________________________________________________
____________________________________________________________________________________________
Director / School official
Title
Date