God's Little Angels Academy
GLA Academy
Where Students Believe, Achieve and Succeed

Please fill in the following form. This is a secured site so that all iformation entered is private and secure.

Student's Information:

Name:*
Date of Birth:*
Address:
Age:*
Gender:*
School Atending:*
Grade:*
Social Security Number:*

(Application will be denied without SSN)

Vouchers:*
If yes, Voucher number:
Expiration Date:
Is this a foster child?:*
If yes, Worker's Name:
Worker's Phone:
-
Will they be visiting the child?:

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Parent/Guardian Information

Mother's Name:
Mother's Address:
Mother's Cell #:
-
Mother's Work #:
-
Father's Name:
Father's Address:
Father's Cell #:
-
Father's Work #:
-

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Emergency Contact Information (A personNOT mentioned above)

Contact 1 Name:
Contact 1 Relationship:
Contact 1 Phone:
-
Can Pick Up?
Contact 2 Name:
Contact 2 Relationship:
Contact 2 Phone:
-
Contact 2 Can Pick up?

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Medical Emergency Contact Information

Child's Physician or Source of Health Care:
Physician's Phone:
-

For EMERGENCIES requiring immediate medical attention, your child will be taken to the nearest hospital emergency room. You signature on the latter portion of this application authorizes the responsible person at GLA to have your child transported to that hospital by car, ambulance, or aid car. My child may also be given emergency treatment by the appropriate GLA staff.

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Transportation Information (if Applicable)

Is Transportation Needed?
If yes, please give all details:

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Medical Section (Complete all Questions)

Is the student in general good health?*
If no, please explain:
Does this student have a IEP/IFSP?:*
If yes, please attach:
Does this student have asthma?*
Is student on medication?*
If yes, for what?
Is student allergic to any foods?:*
If yes, what?:
Does student have any other allergies?:*
If yes, to what?:
Are there any behavioral challenges that we should know about? :

Additional Fees:

  • $1.00 per minute late pick up fee, Charge is per child and will be added to weekly balance due.
  • $5.00 per day late payment fee. Charge is for unpaid balances after Monday and is due at next payment.
  • $35.00 return check charge for all checks returned.
  • $75.00/$100.00  non refundable registration fee for enrollment.
  • Transportation, Before/After School and Drop In Care fees are additional.

Universal Field Trip Permission Universal Field Trip Permission

I hereby request that my child be permitted to participate in field trips such as discovery walks,  the library, parks or any other activities that would involve taking the child outside of the center for his/her benefit in attendance at this facility. I understand that my child will be traveling in vans, buses and cars owned and operated by  God’s Little Angels, Inc and Building Youth Inc., and/or any other contracted transportation companies. Your digital signature at the bottom of this application serves as your agreement.

Waiver Release Form

In exchange for participation in all daily activities such as; trip, walks, library visits, dance, step, swimming, karate, sports, games, running, walking, lining up, eating, playing, falling, hitting/biting with other children, water play, bowling, skating, go carting, transportation and ect. Organized by God’s Little Angels, Inc/ Building Youth, Inc., I agree for myself, my family and all third Parties that:

  • We will observe and agree to all posted rules and warnings and further agree to follow any oral instructions or directions given.
  • We will accept that there are certain inherent risks associated with the aforementioned activities and we assume personal responsibility for personal injury and release GLA from injury, loss or damage.
  • We will agree to defend GLA against all claims, causes of action damages, judgments, attorney’s fees and other costs which may arise.
  • We will agree to pay for all damages to the facilities that may result from our negligence.
  • We will agree that any/all legal actions that may arise shall be resolved under GLA guidelines.

Your digital signature at the bottom serves as your agreement.

Illness Procedures & Self Medication Policy

Any Illnesses such as; pink eye, stomach virus, hacking cough, colds with green and yellow mucous, fever, viruses, flu vomiting or any contagious disease the child will be isolated from the rest of the group. The parent will be contacted immediately. The child must be picked up within an hour after the emergency call is made. The child will need a doctor’s note to return back to school unless an okay is given by a school administrator. If your child is on medication for a documented illness, your health practitioner must complete and validate a medication order form. Medication will not be administered without this form. Children on maintenance drugs such as albuterol inhaler will be supervised while administering the drug. Your digital  signature at the bottom serves as your agreement.

SUMMER CAMP STUDENTS:

Building Youth Inc/GLA will not administer any medication to students/campers.  Parents are responsible for ensuring that their child (ren) is/are well versed on how to self-administer medication. In the event that the student/camper is unable to do so, parents/guardians must have an alternate available to come to our site to administer medication. Your signature at the latter portion of this application notes that you understand clearly that God’s Little Angels/ Building Youth Inc will not administer any medication to students/campers.

Payment Policy

No refunds will be issued. Overpayments will remain as a credit on your account. All Payments are due on Monday in advance. You must pay for the ENTIRE week,   whether or not you use the service (transportation Included). Parents are responsible for full payment during the Christmas and Easter week vacation. A free week form must be completed and signed by a GLA finance person. A two week notice must be given if you withdraw your child (ren) from any of the GLA programs. Otherwise you will be responsible for two weeks of payment. If your vouchers expire and your children are still attending the programs you are responsible for the entire payment. (No exceptions) If you receive vouchers or cash assistance towards your tuition and have already made a payment a credit will be issued to your account. No cash refunds will be issued.  GLA has the right to terminate services of any reason that causes any disruption that may affect the flow of business.                                                                    
Co-payments must be paid each week in advance. Registration fees are non-refundable.

Persons digitally signing/submitting this contract are responsible for payment; Submission of this form implies that I understand that this is a legally binding contract, and I have read it and understand it. I have recieved a copy of the parent handbook.

Parent/Guardian Signature:*
Date:*
Parent/Guardian SSN:*

 

Download and print this form in Spanish. Click here!

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