EARTHKEEPER NATURE SCHOOL ENROLLMENT FORMS PACKET

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EARTHKEEPER NATURE SCHOOL

ENROLLMENT FORMS PACKET

1. Basic Enrollment Form

2. Pick-up Authorization Form (Please notify us if these should change during the school year). 3. Parent Questionnaire

4. Emergency Treatment Authorization Form 5. Field Trip Permission Form

6. Photo & Media Release 7. Sunscreen Release 8. Financial Aid Form 9. Liability Release

10. Policies and Procedures Verification Form / Session Choice / Van Transportation 11. Child’s Health History & Information Form

12. Child’s Statement of Health Form (signed by a physician)

13. Colorado Dept. of Health Certificate of Immunization (signed by a physician) 14. Tuition Agreement

PLEASE RETURN COMPLETED FORMS AND ENROLLMENT FEE TO: Nature & Wildlife Discovery Center

Earthkeeper Nature School PO Box 99

Beulah, CO 81023

Please make checks out to Nature & Wildlife Discovery Center.

Questions? Contact Dave Van Manen at [email protected] or Tami Montoya at [email protected].

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EARTHKEEPER NATURE SCHOOL

1. BASIC ENROLLMENT FORM

Date of Enrollment:___________________ Child’s Name: _____________________________________ Nickname: __________________ Home Address: _________________________________________________________________ Home Phone: __________________Sex: M F Age: _______ Date of Birth: _____________ Family Members: _______________________________________________________________

Mother or Guardian’s Name: ______________________________________________________ Address if different from child’s: __________________________________________________ Home Phone: _____________ Cell Phone: ______________Email: _______________________ Place of Employment (Mother/Guardian):____________________________________________ Address of Employment: ________________________________ Work Phone: _____________ Special Instructions for Reaching you: ______________________________________________

Father or Guardian’s Name: ______________________________________________________ Address if different from child’s: __________________________________________________ Home Phone: _____________ Cell Phone: ______________Email: _______________________ Place of Employment (Father/Guardian):____________________________________________ Address of Employment: ________________________________ Work Phone: _____________ Special Instructions for Reaching you: ______________________________________________ Emergency Contacts:

1. Name: _____________________________________ Relationship to child: ______________ Address: ______________________________________________________________________ Home Phone: _______________ Cell Phone: ______________ Work Phone:________________ 2. Name: _____________________________________ Relationship to child: ______________ Address: ______________________________________________________________________ Home Phone: _______________ Cell Phone: ______________ Work Phone:________________

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EARTHKEEPER NATURE SCHOOL 2. CHILD PICKUP AUTHORIZATION

Persons authorized to pick up your child (Must show photo ID)

Name: _______________________________________________________________________ Address: _____________________________________________________________________ Relationship to Child: ___________________________________________________________ Home Phone: _____________ Cell Phone: ________________Work Phone: _______________

Child’s Name: __________________________________________

Parent / Guardian Name: ________________________________________________________ Parent / Guardian Signature: ____________________________________ Date: _____________

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3. PARENT QUESTIONAIRE

Child‘s name: _____________________________________ Date of Birth: ________________

Parent(s) name: ____________________________________Date of application: ___________

1. Tell us about your child. What are his/her likes, dislikes, interests?

2. What do you consider to be your child‘s greatest strengths and unique skills?

3. What do you consider to be your child’s biggest challenges?

4. What draws you and your family to the Nature Preschool style of education? Are you familiar with the Nature Preschool philosophy? Why do you think your child would be a good fit for this sort of education?

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5. Is your child sensitive to getting dirty or being outdoors for long periods of time? Does your child have any fears associated with the outside world (ex. spiders, snakes,

butterflies)? Please share any challenges that might limit your child‘s ability to be outdoors for a large portion of the school day?

6. The Earthkeeper Nature Preschool believes in the Reggio Emilia Approach to early childhood education. Are you familiar with this child-centered educational approach?

7. Have you observed a learning style that works particularly well/poorly for them?

8. Please tell us a bit about your family. What languages are spoken at home? Does your child have sibling?

9. What are your educational goals for your child?

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4. AUTHORIZATION FOR EMERGENCY TREATMENT Child’s Name: ______________________________________________________

In the event of an emergency I hereby give my permission for Earthkeeper Nature school care staff to access emergency medical services for my child, including transport to the nearest health care facility, to receive emergency medical or surgical care and treatment. It is understood that a conscientious effort will be made to locate me, and I accept the expense of care and transport.

Name of Parent/Guardian: ________________________________________________

Signature of Parent/Guardian: __________________________________Date: _____________

Name of Parent/Guardian: ________________________________________________

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EARTHKEEPER NATURE SCHOOL 5. FIELD TRIP PERMISSION FORM

Child’s Name ______________________________________________ Date ______________ By signing below, I give the Earthkeeper Nature School permission for my child to participate in the field trip or excursion to ____________________________________________________ that will take place on the following date: ________________________. I can be reached at the following phone number during the time of the field trip: ______________________________ .

Parent or Guardian Name _______________________________________________________

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6. PHOTO & MEDIA RELEASE

Child’s Name: ____________________________________________________ Please check one below.

o

Yes, I give permission for my child to be photographed or videotaped while attending Earthkeeper Nature School. By checking “yes” and signing this consent form, I give permission for my child’s first and last name and/or photograph to be used in publications, presentations, videos, web pages, or news releases produced by Earthkeeper Nature School and the Nature & Wildlife Discovery Center. My child’s first and last name and/or photograph may be included in news releases distributed to newspapers and other news media.

NOTE: No payment will be made to a child photographed under terms of this release or to his/her family if and when the photographs are used in school publications, presentations, video productions, or web sites. Parents/guardians waive the right to preview or approve the finished photographs or video.

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No, I do NOT want my child to be photographed or videotaped while attending Earthkeeper Nature School. Checking “no” and signing this form means that my child’s name and/or photograph may NOT be used in publications, presentations, videos, web pages, or news releases produced by Earthkeeper Nature School and the Nature & Wildlife Discovery Center. My child’s first and last name and/or photograph may NOT be included in news releases distributed to newspapers and other news media.

Parent/Guardian Name: _____________________________________________ Parent/Guardian Signature: __________________________________________ Date: ___________________

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EARTHKEEPER NATURE SCHOOL 7. PERMISSION TO APPLY SUNSCREEN Child’s Name: ________________________________________________

As the parent or guardian of the above child, I give my permission for school staff to apply a sunscreen product of SPF 15 or higher to my child, as specified below, when he or she will be playing outside, especially during the months of March through October and between the daily times of 10 a.m. and 4 p.m. I understand that t sunscreen may be applied to exposed skin, including but not limited to the face, tops of the ears, nose and bare shoulders, arms, and legs. I have checked all applicable information regarding the type and use of sunscreen for my child:

❑ I do not know of any allergies my child has to sunscreen.

❑ Staff may use the sunscreen of their choice following the directions or recommendations printed on the bottle.

❑ I have provided the following brand/type of sunscreen for use on my child:

_________________________________________________________________________

❑ My child is allergic to some sunscreens. Please use only the following brand(s) and type(s) of sunscreen: _______________________________________________________

❑ For medical or other reasons, please do not apply sunscreen to the following areas of my child’s body: ___________________________________________________________ Parent/Guardian Name: ____________________________________________________ Parent/Guardian signature: __________________________________________________ Date: __________________________

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8. REQUEST FOR FINANCIAL AID

If you look at our tuition price and think “I can’t afford that” then we suggest you fill out this form. We at Earthkeeper Nature School do not want a lack of financial resources to be the reason why a family does not send their child to our preschool. Hence, we will do our very best to provide the financial assistance needed so your child can attend.

Child’s Name: ________________________________

Circle one: 2-half day preschool 4-half day preschool kindergarten

Mother or Guardian’s Name: ______________________________________________________ Address: ______________________________________________________________________ Home Phone: _____________ Cell Phone: ______________Email: _______________________ Place of Employment (Mother/Guardian):____________________________________________ Address of Employment: ________________________________ Work Phone: _____________ Father or Guardian’s Name: ______________________________________________________ Address if different from child’s: __________________________________________________ Home Phone: _____________ Cell Phone: ______________Email: _______________________ Place of Employment (Father/Guardian):____________________________________________ Address of Employment: ________________________________ Work Phone: _____________ How many people live in your household? ___________ (To establish family size please count all people who meet all of the following criteria: living in the same household as the child; supported by the income of the parent(s) or legal guardian(s) of the child; related to the parent(s) or legal guardian(s) by blood, marriage, or adoption. Note that the child’s parent(s) / guardian(s) are included in this count).

Family/Household Income: _____________________________ (Count the following income: Gross wages or salaries, and net income from self-employment, of all adults counted in the family size; cash benefits to adults or children counted in the family size, such as Social Security, Supplemental Security Income, Emergency Assistance, Unemployment or Workers Compensation, training stipends, veteran’s benefits, alimony, child support, DSHS foster care grant, pensions, periodic insurance or annuity payments or scholarships/grants for living expenses. Income does not include: Non-cash benefits, such as food stamps, housing vouchers, Medicaid, Medicare, employee fringe benefits; food or housing received in lieu of wages; assets drawn down, such as cash from sale of an asset or bank withdrawals; one-time gifts, loans, lump-sum inheritances, insurance payments, or compensations for injury.)

Please attach proof of family income to this form. This may include a tax return or other documentation that shows your families annual income.

Amount of financial aid requested: _______________ (Note that annual tuition for the 2-Half Day Preschool program is $1850, broken into 10 payments of $185, plus there is a $100 enrollment fee, for a total of $1950. The annual tuition for the 4-Half-Day Preschool or the Kindergarten is $3330, broken into 10 payments of $333, plus there is a $100 enrollment fee, for a total of $3430.)

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EARTHKEEPER NATURE SCHOOL 9. RELEASE OF LIABILITY

I, ___________________________, hereby acknowledge that I have voluntarily asked to enroll my child in the Earthkeeper Nature School operated by the Nature and Wildlife Discovery Center.

I have been informed that this program involves outdoor activities and that injuries could result from my child’s participation in the program, including injuries from the following: insect bites and stings, exposure to the sun, lightning, falling rocks or trees, exposure to extremes of heat or cold, and other potential risks.

I AM AWARE THAT THIS PROGRAM INCLUDES POTENTIALLY HAZARDOUS ACTIVITIES, AND I AM VOLUNTARILY ENROLLING MY CHILD IN EARTHKEEPER NATURE PRESCHOOL TO PARTICIPATE IN THESE ACTIVITIES WITH KNOWLEDGE OF THE POTENTIAL HAZARDS INVOLVED AND HEREBY AGREE TO ACCEPT ANY AND ALL RISKS OF INJURY TO MY CHILD.

As lawful consideration for being permitted by the Nature and Wildlife Discovery Center for my child to attend the Earthkeeper Nature School and participate in these activities and use their facilities, I hereby agree that I, my heirs, distributes, guardians, legal representatives and assigns will not make a claim against, sue, attach the property of, or prosecute the Nature and Wildlife Discovery Center or its employees, agents or contractors, or any of its affiliated organizations for injury or damage, regardless of cause, including negligence or other acts, howsoever caused, by any employee, agent or contractor of the Nature and Wildlife Discovery Center as a result of my child’s enrollment participation in the Earthkeeper Nature School.

In addition, I hereby release and discharge the Nature and Wildlife Discovery Center, its employees, agents or contractors and its affiliated organizations from all actions, claim or demands I, my heirs, distributees, guardians, legal representatives or assigns now have or may hereafter have for injury or damage resulting from my child’s participation in Earthkeeper Nature School activities.

I HAVE CAREFULLY READ THIS AGREEMENT AND FULLY UNDERSTAND ITS CONTENTS. I AM AWARE THAT THIS IS A RELEASE OF LIABILITY AND A CONTRACT BETWEEN MYSELF AND THE NATURE AND WILDLIFE DISCOVERY CENTER AND/OR ITS AFFILIATED ORGANIZATIONS, AND I HAVE SIGNED IT OF MY OWN FREE WILL.

Name of Child: _________________________________________________ Name of Parent or Guardian: _______________________________________ Signature of Parent or Guardian: ___________________________________ Date: _____________________________

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EARTHKEEPER NATURE SCHOOL

10. POLICIES AND PROCEDURES ACKNOWLEDGEMENT / SESSION CHOICE / NEED FOR VAN TRANSPORTATION

By signing, I acknowledge that I have received a copy of the Policies and Procedures and that I understand that I am responsible for knowing and following the Policies and Procedures while my child is attending the Earthkeeper Nature School. Any questions about the Policies and Procedures should be brought to the preschool staff. Note that the information in the Policies and Procedures is subject to change. I understand that I will be notified of any changes and accept the same responsibility for knowing and following the updated Policies and Procedures.

Child’s Name: _______________________________________________________________ Parent/Guardian Name: ________________________________________________________ Parent/Guardian Signature _________________________________ Date: ________________

PLEASE CIRCLE THE WEEKLY SESSION YOU PREFER TO SEND YOUR CHILD (We will do our best to honor your preference and will let you know if a spot on that session is not available. Also, note that the Monday and Tuesday classes will be in the Mountain Park in Beulah, and the Wednesday and Thursday classes will be at the River Campus [Nature Center] in Pueblo):

2-Half Day Preschool, Monday / Wednesday Morning 2-Half Day Preschool, Monday / Wednesday Afternoon

2-Half Day Preschool, Tuesday / Thursday Morning 2-Half Day Preschool, Tuesday / Thursday Afternoon

4-Half Day Preschool, Monday thru Thursday Morning 4-Half Day Preschool, Monday thru Thursday Afternoon

Kindergarten, Monday thru Thursday Morning Kindergarten, Monday thru Thursday Afternoon

VAN TRASNPORTATION TO BEULAH

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EARTHKEEPER NATURE SCHOOL 11. HEALTH HISTORY AND INFORMATION

Child’s Name: _____________________________________ Nickname: __________________ Home Address: _________________________________________________________________ Home Phone: __________________Sex: M F Age: _______ Date of Birth: _____________ Mother or Guardian’s Name: ______________________________________________________ Father or Guardian’s Name: ______________________________________________________ Medical Insurance: Private Insurance Medicaid Uninsured

Doctor’s Name: ___________________________________ Phone #: ____________________ Doctor’s Address: ______________________________________________________________ Dentist’s Name: ___________________________________ Phone #: ____________________ Dentist’s Address: ______________________________________________________________ Preferred Hospital in Case of Emergency: ___________________________________________

Allergies (explain nature and severity of reaction):

Hay Fever: ___________________________________________________________________ Plant Poisoning: _______________________________________________________________ Insect Stings: _________________________________________________________________ Penicillin: ____________________________________________________________________ Other drugs: __________________________________________________________________ Animals: _____________________________________________________________________ Food: ________________________________________________________________________ Other: ________________________________________________________________________

Health History (explain any pertinent information):

Ear Infections: _________________________________________________________________ Diabetes: _____________________________________________________________________ Heart disease/defect: ____________________________________________________________ Convulsions/seizures: ___________________________________________________________ Asthma: ______________________________________________________________________ Nosebleeds: ___________________________________________________________________ Skin Conditions: _______________________________________________________________ Communicable Diseases: ________________________________________________________

Stomach / Bowel Disorder: _______________________________________________________ Urinary Disorder: _______________________________________________________________

Mental Disorder: _______________________________________________________________ Autism: ______________________________________________________________________

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Vision Problems: _______________________________________________________________ Hearing Problems: ______________________________________________________________ Injuries: _____________________________________________________________________

Other:_______________________________________________________________________________ _________________________________________________________________

Does your child have any special needs? Yes No If yes, please list and explain:

_____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ ____________________________________

Is your child on any medications? Yes No

If yes, please list the names of the medications and explain reasons for them:

_____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _________________________________________________________

Is your child fully immunized? Yes No

Complete immunization records must be provided on or before the first day the child is in care. Operations or serious injuries (dates):

_____________________________________________________________________________________ _____________________________________________________________________________________ ________________________________________________________________

Does your child have any physical limitations: Yes No

If yes, please explain: ____________________________________________________________

_____________________________________________________________________________________ _______________________________________________________________________

Does your child have any dietary limitations: Yes No

If yes, please explain: ____________________________________________________________

_____________________________________________________________________________________ _______________________________________________________________________

Parent Name filling out Health Form: _______________________________________________ Signature: _________________________________________________ Date: ______________

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EARTHKEEPER NATURE SCHOOL 12. CHILD’S STATEMENT OF HEALTH

Child’s Name: _____________________________________ Nickname: __________________ Home Address: _________________________________________________________________ Home Phone: __________________Sex: M F Age: _______ Date of Birth: _____________ Date of child’s most recent examination: ___________ Date next visit is required ___________ Known allergies: _______________________________________________________________ Medications being taken, prescribed routine, possible side effects:_________________________ ______________________________________________________________________________ ______________________________________________________________________________ Past Illnesses (check those the child has had and give approximate dates):

Chicken Pox_________ Rubeola____________ Rubella___________ Rheumatic Fever________ Asthma____________ Hay Fever_____________ Diabetes_______________ Mumps_____________ Epilepsy______________ Whooping Cough________ Poliomyelitis________ Other_________________ ________________________________________________________________________ If tuberculin test given: Date______________ Result________________

If chest X ray taken: Date______________ Result________________

Date of Screening for: Vision___________ Hearing____________ Dental_____________ Surgery/Accidents/Illnesses/Chronic or Handicapping Problems: _________________________ ______________________________________________________________________________ ______________________________________________________________________________ Describe any physical condition requiring special attention by school staff:__________________ ______________________________________________________________________________ ______________________________________________________________________________ This child (circle one) is is not physically and/or emotionally able to participate in the Earthkeeper Nature Preschool program.

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Comments:____________________________________________________________________ _____________________________________________________________________________ Next physical exam is due:________________ (A date MUST be entered!)

Health Provider Name___________________________________ Phone _________________ Address_____________________________________________________________________ Health Provider Signature _________________________________ Date: ________________

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14. TUITION AGREEMENT By signing this agreement, I understand that:

• 2-Half Day Preschool: Annual tuition of $1850 for the school year running August 12, 2019 through May 28, 2020 is broken up into ten monthly payments of $185.

• 4-Half Day Preschool and Kindergarten: Annual tuition of $3330 for the school year running August 12, 2019 through May 28, 2020 is broken up into ten monthly payments of $333. • Monthly tuition payments are expected to be paid by the 21st_{of the month prior to the month}

being paid for (example: tuition for October needs to be paid by September 21).

• If you are utilizing our van transportation for Beulah, the monthly fee of $45 will be added to the monthly school tuition payment and is to be paid at the same time as the school monthly tuition payment.

• Similar to tuition fees at other schools, there are no refunds for days missed.

• A one-time, non-refundable enrollment fee of $100 and the last month’s tuition payment, also non-refundable, are due at the time of enrolling your child in the Earthkeeper Nature School.

• If my child is starting school after the school year has begun, I understand I am to pay the registration fee and final month’s tuition payments at time of enrollment.

• I will pay a $15.00 late fee for a monthly tuition payment that is not paid by the due date (21st_{of the month prior to the month being paid for).}

• If tuition payment is not paid by the 28th_{of the month prior to the monthly payment being}

paid for, I understand that my child may not return to school until the tuition payment plus the late fee is paid. If payment is not made by the 15th of the month that is unpaid for, my child will be considered as withdrawn from school.

• There will be a $15.00 service charge on returned checks and thereafter, payments must be made with cash, credit card, or debit card.

• I understand that the registration fee and the last month’s tuition payment are non-refundable. • I realize the importance of my child experiencing the full school year program and will make

every effort possible to have them complete the full school year.

By signing, I acknowledge that I have read and understand the above agreement.

Child’s Name: _______________________________________________________________ Parent/Guardian Name: ________________________________________________________ Parent/Guardian Signature _________________________________ Date: ________________