2014-2015 ELC Application - Liberty Christian Academy

LCA Early Learning Center
2014-2015 APPLICATION
Application Process
Step 1
Submit a completed application with a non-refundable application fee of $50 to the elc main
office. be sure to sign the statement of cooperation on page four of this form.
Step 2
Submit the following documentation to the ELC Main Office
____Original certified birth certificate
____Original social security card
____Any developmental evaluations or IEP forms
____Custody documentation if student(s) does not reside with birth parents or both parents
Step 3
Once all of the above documentation has been received, our Main Office staff will call you for
an interview. Preferably both parents, but at least one parent must interview with the ELC
Director.
Step 4
Following the interview, parents must establish a family account by signing a tuition contract
and setting up FACTS, should they choose a monthly payment plans.
The enrollment procedure is considered complete when the above paperwork has been filed, an interview has
been completed, the financial contract and FACTS have been established, and the school entrance physical
with verification of all required immunizations is filed in the ELC office.
If the administration can be of any assistance in helping you complete the enrollment process, please feel free
to contact us at the number below.
LCA Early Learning Center
100 Mountain View Road, Lynchburg, VA 24502-2272
Phone: (434) 832-2074 (Mon. - Fri. 8:30 a.m. - 4:30 p.m.) * Fax (434) 582-3840
[email protected] * www.LCAbulldogs.com
1. CONTACT INFORMATION
____________________________________________________________________________________________________________
STUDENT LAST NAME
FIRST NAME
MIDDLE
NAME HE/SHE PREFERS TO USE
____________________________________________________________________________________________________________
ADDRESS
STREET
CITY
STATE
ZIP
COUNTY
____________________________________________________________________________________________________________
AGE
DATE OF BIRTH
GENDER
SOCIAL SECURITY #
HOME PHONE
____________________________________________________________________________________________________________
FATHER’S NAME
PLACE OF EMPLOYMENT
WORK PHONE
CELL PHONE
EMAIL ADDRESS
____________________________________________________________________________________________________________
MOTHER’ NAME
PLACE OF EMPLOYMENT
WORK PHONE
CELL PHONE
EMAIL ADDRESS
MARITAL STATUS
MARRIED__________ WIDOWED__________ SEPARATED__________ DIVORCED__________ SINGLE__________
IF SEPARATED, LEGAL GUARDIAN___________________________________________________________________________
Name
(Relationship to Child)
HAS YOUR CHILD HAD ANY OTHER CHILD CARE EXPERIENCE? YES__________ NO___________
IF YES, PLEASE GIVE NAME, LOCATION AND TYPE OF CARE____________________________________________________
CHURCH ATTENDING:
NAME/ADDRESS
NAME OF PASTOR
FATHER___________________________________________________________________________________________
MOTHER__________________________________________________________________________________________
CHILD______________________________________________________________________________________________
NAMES OF OTHER CHILD(REN) IN THE FAMILY
AGE
GRADE
SCHOOL ATTENDING
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
PATERNAL GRANDPARENTS’ NAME
ADDRESS
__________________________________________________________________________________________________
MATERNAL GRANDPARENTS’ NAME
ADDRESS
2. SCHEDULE DESIRED
_____Early Room 7:00-8:00am
_____5 half days*
_____5 full days**
_____5 extended care***
_____2 half days TTH
_____2 full days TTH
_____2 extended care TTH
_____3 half days MWF _____3 full days MWF _____3 extended care MWF
*A half day runs 8:00 to 12:15
**A full day runs 8:00 to 3:15
***Extended care runs 3:15 to 5:45
3. PERSON TO CONTACT IF PARENTS CANNOT BE REACHED:
____________________________________________________________________________________________________________
NAME
WORK PHONE
HOME PHONE
RELATIONSHIP TO CHILD
Persons other than parents who are authorized and have ELC I.D. cards to take child from Center:
____________________________________________________________________________________________________________
NAME
WORK PHONE
HOME PHONE
RELATIONSHIP TO CHILD
____________________________________________________________________________________________________________
NAME
WORK PHONE
HOME PHONE
RELATIONSHIP TO CHILD
____________________________________________________________________________________________________________
NAME
WORK PHONE
HOME PHONE
RELATIONSHIP TO CHILD
IS THERE ANYONE NOT ALLOWED TO PICK UP YOUR CHILD?
____________________________________________________________________________________________________________
NAME
RELATIONSHIP TO CHILD
4. MEDICAL AUTHORIZATION
__________________________________________________________________________________________
NAME OF CHILD’S PHYSICIAN
PHONE
Does the child have any physical handicaps, disabilities or special medical conditions? Yes______ No______
If yes, please explain:___________________________________________________________________________________________
____________________________________________________________________________________________________________
Does the child have any known allergies? Yes_____ No_____ If yes, please explain:_________________________________________
____________________________________________________________________________________________________________
Is the child regularly taking any medication? Yes______ No______ If yes, please explain:____________________________________
____________________________________________________________________________________________________________
Do you authorize LCA personnel to administer routine medical treatment? (Band-Aid, antiseptic, etc.) Yes______ No______
**DO YOU AUTHORIZE LCA TO SHARE YOUR CHILD’S HEALTH, MEDICAL AND EMERGENCY CARE INFORMATION (i.e., ASTHMA,
ALLERGIES, DIETARY NEEDS, ETC) WITH THE DIRECTOR OF THE EARLY LEARNING CENTER AND YOUR CHILD’S TEACHERS?
Yes_____ No______
If “NO”, please return to the school in a sealed envelope addressed to LCA school nurse.
The ELC agrees to notify the parent/guardian whenever the child becomes ill, and the parent/guardian agrees to pick up thereafter
as soon as possible.
In case of accident or emergency illness, the Early Learning Center will make every effort to contact the parent or guardian. If
contact cannot be made, parent or guardian hereby authorizes LCA and/or medical personnel to render treatment, which in their
judgment, is deemed necessary in the care of this child.
Agreed to this____________________ Day of____________________ 20____________________
By_____________________________________________________
SS#____________________________________________________
Parent or Guardian
By_____________________________________________________
SS#____________________________________________________
Parent or Guardian
5. DISCRIMINATION POLICY
No person shall be denied enrollment, be excluded from participation in, be denied the benefit of or subject to discrimination in any
program or activity, on the basis of sex, race, color, national origin or ethnic group. For the safety and well-being of our students and
employees, students and/or employees with a life threatening communicable disease may not attend or work at LCA. Decisions
regarding attendance or employment will take into account multiple medical professionals with expertise in the disease. As a Bible
based educational institution, LCA adheres to the Biblical teaching that homosexuality is not an acceptable lifestyle. LCA does not
employ teachers or accept students who are homosexual or bi-sexual.
6. COMPLIANCE AGREEMENT
In compliance with Virginia Law, no student will be considered enrolled nor permitted to attend for whom a certified copy of the
student’s birth record (or affidavit explaining inability to present a certified copy) and a complete school entrance physical (to
include verification of required immunization) have not been received. A late processing fee of $25 will be applied to the account of
any student for whom the Virginia School Entrance Health Form has not been received by June 1, by 15 working days after
notification of acceptance or by the first day of attendance, whichever date occurs first. If the deadline cannot be met due to
insurance requirements or acceptance after June 1, contact the ELC at (434) 832-2074 with the date it will be completed.
7. ELC STATEMENT OF COOPERATION
1.
In full cooperation with The Early Learning Center, we will attend the parent sessions and family events planned by the
Center. We sincerely pledge our loyalty to the aims and ideals of the school and will bring all questions and criticisms
directly to the administration so that they may be properly considered by those in authority.
2.
Parents will pay tuition as stated on the ELC contract.
3.
I will submit all results of developmental evaluations to the ELC.
4.
The faculty and administration are hereby given full discretion in the discipline of our child. This would include using the
time-out chair, notes and phone calls to parents, and conference with the director.
5.
The school reserves the right to dismiss any student who does not cooperate with Early Learning Center policies or any
parent who does not cooperate with Early Learning Center policies. We understand that all students are accepted on a six
week trial basis.
6.
It is our understanding that the policy for the school is to make no refund on fees. Tuition may only be waived by the
director upon withdrawal if an exception is made. Otherwise, tuition is due in full, regardless of attendance.
7.
We hereby authorize the Early Learning Center to permit our child to participate in all school activities, including but not
limited to school sponsored field trips away from the school premises, and absolve the school from liability to us or our
child because of any injury to our child at school or during any school activity.
8.
We agree to notify the LCA Early Learning Center promptly of any change in our address, telephone, employment, or
marital status.
9.
We have read the Principles and Policies Handbook for the Early Learning Center in its entirety, and are in full agreement as
so stated.
10. Pictures – I hereby grant LCA permission to use my son or daughter’s photograph in print, electronic and video formats or in
other official LCA print publications and I acknowledge LCA’s right to appropriately crop and/or correct the photograph as
needed. LCA has the right to reproduce, use, exhibit, display, broadcast, distribute and create derivative works of the
photographed images of your son or daughter for USE IN CONNECTION WITH THE ACTIVITIES OF THE ACADEMY FOR
PROMOTING, ADVERTISING, PUBLICIZING, OR EXPLAINING LCA OR ITS ACTIVITIES.
____________________________________________________________________________________________________________
Parent Signature
Date
LCA Early Learning Center
100 Mountain View Road, Lynchburg, VA 24502-2272
Phone: (434) 832-2074 (Mon. - Fri. 8:30 a.m. - 4:30 p.m.) * Fax (434) 582-3840
[email protected] * www.LCAbulldogs.com

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