Application Form - School Year 2011/2012 Office Use: Date Rec.

Epiphany Lutheran Nursery School1400 Horsepen Road

Richmond, Virginia 23226-33749(804) 282-7506

elns_73@yahoo.com

Return the completed application form with a $25 non-refundable application fee to the above addressAre you a member of Epiphany Evangelical Lutheran Church? (Members are exempt from application fee).

Date of Application, _

Child's Name, Sex Birth Date, _

Name your child should be called at school Home Phone _

Add ress, City ,Zip _

Parents names: Father Cell Phone, Business Phone _

Mother Cell Phone Business Phone _

Child's age as of Sept. 30, 2011 years __ months

PROGRAM DESIRED: (check one)__ t-Day Friday 15 months to 24 months by September 30, 2011 *

__ 2-Day Monday & Wednesday 15 months to 24 months by September 30, 2011 *

__ 2- Day Tuesday & Thursday 15 months to 24 months by September 30, 2011 *

__ 5-Day Monday - Friday 15 months to 24 months by September 30, 2011 *

*In developmental walking stage and not requiring a morning nap.

__ 2-Day Tuesday & Thursday age 2 by September 30, 2011

__ 3-Day Monday, Wednesday, Friday age 2 by September 30, 2011

__ 5-Day Monday - Friday age 2 by September 30, 2011

__ 3- Day Monday, Wednesday, Friday, age 3 years by September 30, 2011

__ 5- Day Monday - Friday age 3 years by September 30, 2011

__ 5-Day Pre-K Monday - Friday age 4 years by September 30, 2011

__ 3-Day Pre-K Monday, Wednesday, Friday, age 4 years by September 30, 2011

__ 5-Day Jr.-K Monday - Friday 5 years old by September 30,2011 (older 4's with permission from Director)

(continue on next page)

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Does your chtld have any special needs? If yes, please describe briefly on this application.

This application does not ensure enrollment in Epiphany Lutheran Nursery School. An application and non-refundableapplication fee must be on file in order for your child to be placed on the waiting list. When an application is accepted, youwill be notified and a contract will be issued.

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Epiphany Lutheran Nursery School1400 Horsepen Road

Richmond, Virginia 23226-3749(804)282-7506

elns_73@yahoo.com

Tuition -2011-2012 school year

Non- Refundable FeesApplication Fee (due With application)Initial Processing Fee (1 time fee for new students. Due with contract)First tuition payment (due with signed contract)

1day2,3, ""4& 5 day

TuitionThere are two tuition payment plans from which to choose: payment in two installments or paymentmonthly. Tuition due dates for the two payment option are indicated below. The payment monthly

"option will include an additional $5.00 per month carrying charge.

$25$50

$100$200

5 - Day Program4 - Day Program3 - Day Program2 - Day Program1 - Day Program

Annual Tuition$3150$2520$1890

" $1260$630

Non-refundable1st payment$200$200$200$200$100

Due Aug. 1$1475$1160$845$530$265

Due Jan. 1$1475$1160$845$530$265

Students entering ELNS at any point after the first day of school are required to pay the full amount ofthe nonrefundable fee. The remainder of the tuition will be prorated.

Late Fees:Payments received more than 5 days late will be"assessed a $10.00 late fee.

. ~~~.t.' '.

Epiphany Lutheran Nursery School1400 Horsepen Rd. Richmond, Virginia 23226-3749 (804)282-7506

Student Information Sheet Date _

Please complete all questions and update all information, whenever necessary, throughout the year.

Full name of child, Birth date. _

Name your child should be called at school, _ Home Phone _

Address. City Zip, _

Father's Full name Employer _

Business Address Work Phone _

cell phone # pager # _

Father's nickname or name he is generally called by friends and family _

Mother's Full Name. Employer _

Business Address Work Phone _

cell phone # pager # _

Mother's current occupation _

Mother's nickname or name she is generally called by friends and family _

Are there any health problems, allergies, recent surgery, or other conditions that will interfere with your child's participation

Is your child receiving therapy (speech, etc.) if so, with whom and where? _

Has anything happened recently within the family that might cause the child to experience an emotional upset? (example:

death of relative or pet, separation of parents, new baby) _

Names and ages (when school starts in Sept.) of Siblings, _

Is your child adopted? Does he/she know? Are any siblings adopted? _

Is this child living at home with both parents? Please list other persons living in the home (other than siblings)

Is your child currently attending any other preschool program? If yes, which one? _

Has this child had a school or playgroup experiences other than at Epiphany? If yes, where & dates? _

Church membership or religious preference _

EMERGENCY INFORMATION

Child's Doctor's Name, address & telephone _

Preferred hospital -r-t-' ----, _

Is your child allergic to any foods, drugs or other substance? (please list) Please discuss the severity of these allergies

with your child's teacher. _

Action to take in the event of an allergic reaction/emergency: _

Please note that by law we are unable to administer medication of any kind without completed medical consent form and

written permission from child's physician.

Please list any places (other than work) where parents or guardians might be reached on a regular basis during school

hours _

In the event a parent or guardian cannot be reached, please list the person (and relationship to your child) you would like

us to contact in a medical emergency situation (more than one can be listed) _

Please list names, relationship to child addresses, and phone numbers of two persons who may be called if your child

needs to go home during school hours because of illness, _

Permission is given to seek medical attention if necessary. Permission is granted for any staff member to apply band-

aids or ice packs to minor injuries. Permission is also granted for school personnel or rescue squad to transport my child

to an emergency facility.

Signature _

Parent or Guardian Date

Please use the space below for any additional information that might help us serve both this child and his/her family.

COMMONWEALTH OF VIRGINIASCHOOL ENTRANCE HEALTH FORM

Part II - Certification of Immunization

Section ITo be completed by a physician, registered nurse, or health department official.

See Section II for conditional enrollment and exemptions.

(A copy of the immunization record signed or stamped by a physician or designee indicating the dates of administrationincluding month, day, and year of the required vaccines shall be acceptable in lieu of recording these dates on this form aslong as the record is attached to this form.)Only vaccines marked with an asterisk are currently required for school entry. Form must be signed and dated by theMedical Provider or Health Department Official in the appropriate box.

-Student's Name: Date of Birth: 1__ 1__ 1__ 1

Last First Middle Mo. Day Yr.

IMMUNIZATION RECORD COMPLETE DATES (month, day, year) OF VACCINE DOSES GIVEN

"Diphtheria, Tetanus, Pertussis (DTP, DTaP) 1 2 3 4 5

"Diphtheria, Tetanus (DT) or Td (given after 7 1 2 3 4 5years of age)

*T dap booster (6th grade entry) 1

itis (IPV, OPV) 1 2 3 4

uenzae Type b 1 2 3 4)

, fn~ ~i,ilr!rf'n <60 months of age

mococcal (PCV conjugate) 1 2 3 14 1for children <2 years of age

Measles, Mumps, Rubella (MMR vaccine) 1 2

*Measles (Rubeola) 1 2 Serological Confirmation of Measles Immunity:

1 Serological Confirmation of Rubella Immunity:

"Mumps 1 2

*Hepatitis B Vaccine (HBV) 1 2 30 Merck adult formulation used

"Varicella Vaccine 1 2 Date of Varicella Disease OR Serological Confirmation of VaricellaImmunity:

Hepatitis A Vaccine 1 2

Meningococcal Vaccine 1

I Human Papillomavirus Vaccine 1 2 3

I Other 1 2 3 4 5

Other 1 2 3 4 5

I certify that this child is ADEQUATELY OR AGE APPROPRIATELY IMMUNIZED in accordance with the MINIMUM requirements for attending school, childcare or preschool prescribed by the State Board of Health's Regulations for the Immunization of School Children (Minimum requirements are listed in Section III).

Signature of Medical Provider or Health Department Official: Date (Mo., Day, Yr.):_I_I __

MCH 213 F revised 4/07 2

1-

Student's Name: Date of Birth: '- L-LJ

Section IIConditional Enrollment and Exemptions

MEDICAL EXEMPTION: As specified in the Code of Virginia § 22.1-271.2, C (ii), I certify that administration of the vaccine(s) designated below would bedetrimental to this student's health. The vaccine(s) is (are) specifically contraindicated because (please specify):

DTPIDTaprrdap:Lj; DTrrd:[~; OPV/IPV:Lj; Hib:[~; Pneum:~; Measles:[_l; Rubella: [_1; Mumps:[--1; HBV:U; Varicella:[_l

This contraindication is permanent: L1,or temporary ~ and expected to preclude immunizations until: Date (Mo., Day, Yr.): I_LI~.

Signature of Medical Provider or Health Department Official: Date (Mo., Day, Yr.): 1_1_1_1

RELIGIOUS EXEMPTION: The Code of Virginia allows a child an exemption from receiving immunizations required for school attendance if the student or thestudent's parent/guardian submits an affidavit to the school's admitting official stating that the administration of immunizing agents conflicts with the student's religioustenets or practices. Any student entering school must submit this affidavit on a CERTIFICATE OF RELIGIOUS EXEMPTION (Form CRE-I), which may be obtained atany local health department, school division superintendent's office or local department of social services. Ref. Code a/Virginia § 22.1-271.2, C (i).

Signature of Medical Provider or Health Department Official: Date (Mo., Day, Yr.): 1 I I I

CONDITIONAL ENROLLMENT: As specified in the Code a/Virginia § 22.1-271.2, B, I certify that this child has received at least one dose of each of the vaccinesrequired by the State Board of Health for attending school and that this child has a plan for the completion of his /her requirements within the next 90 calendar days. Nextimmunization due on _

Section IIIRequirements

*Minimum Immunization Requirements for Entry into School and Day Care (requirements are subject to change)

o 3 DTP or DTaP - at least one dose ofDTaP or DTP after 4th birthday unless received 6 doses before 4th birthdayo Tdap - booster required for entry into 6th grade if at least 5 years since last tetanus-containing vaccineo 3 Polio - at least one dose after 4th birthday unless received 4 doses of all OPV or all IPV prior to 4th birthdayo Hib - 2-3 doses in infancy; 1 booster between 12-15 months; 1 dose between 15-60 months if unvaccinated, for children up to

60 months of age onlyo Pneumococcal- 2-4 doses, depending on age at 151 dose for children up to 2 years of age onlyo 2 Measles - 15t dose on/after 12 months of age; 2nd dose prior to entering kindergarteno 1 Mumps - on/after 12 months of ageo 1 Rubella - on/after 12 months of age

Note: Measles, Mumps, Rubella requirements also met with 2 MMR - 15t dose on/after 12 months of age; 2nd dose prior toentering kindergarten

o Hep B-3 doses required (2 doses if Merck adult formulation given between 11 - 15 years of age; check the indicated box inSection I if this formulation was used)

o 1 Varicella - to susceptible children born on/after January 1, 1997; dose on/after 12 months of age

* Additional Immunizations Required at Entry into 6th Grade

o Tdap - booster required for entry into 6th grade if at least 5 years since last tetanus-containing vaccine

For current requirements consult the Division ofImmunization web site at http://www.vdh.virginia.gov/epiderniologylimmunization

Certification of Immunization 04/07

MCH 213 F revised 4/07 3

Part ill --COMPREHENSIVE PHYSICAL EXAMINATION REPORT

A qualified licensed physician, nurse practitioner, or physician assistant must complete Part III. The exam must be done no longer than one year before entryinto kindergarten or elementary school (Ref. Code of Virginia § 22.1-270). Instructions for completing this form can be found at www.vahealth.orglschoolhealth

Student's Name: Date of Birth: Sex: 0 M D FPhysical Examination

Date of Assessment: __ 1__ 1_-1 = Within normal 2 = Abnormal finding 3 = Referred for evaluation or treatment.•...

Weight: lbs. Height: ft.s:: --- --- in. 1 2 3 I 2 3 1 2 3'"e Body Mass Index (BMI): BP'" HEENT Neurological Skin'" 0 0 0 0 0 0 0 0 0'"'" 0 Age I gender appropriate history completed'" Lungs Abdomen Genital< 0 0 0 0 0 0 0 0 0

..c: 0 Anticipatory guidance provided;::: Heart 0 0 0 Extremities 0 0 0 Urinary 0 0 0<"I TB Risk Assessment: 0 No Risk o PositivelReferred'"il:i Mantoux results: rnm

EPSDT Screens Required for Head Start - include specific results and date:Blood Lead: HctlHgb

Assessedfor: Assessment Method: Within normal Concern identified: Referred for Evaluation';i Emotional/Social.•...s::

Problem Solving'" s::e '"1=><'" LanguagelCommunication~ b",rrJ;> Fine Motor Skills'"A

Gross Motor Skills

0 Screened at 20dB: Indicate Pass (P) or Refer (R) in each box.

bJJ~

~

1000

I

2000

I

4000

I

o Referred to AudiologistlENT o Unable to test - needs rescreens:: -'c ~ o Permanent Hearing Loss Previously identified: Left _Right<"I ••••

'" c.>il:irrJo Hearing aid or other assistive device

o Screened by OAB (Otoacoustic Emissions): o Pass o Refer

o With Corrective Lenses (check if yes)

o Problem Identified: Referred for treatment

o No Problem: Referred for prevention

o No Referral: Already receiving dental care

s:: s:: I Stereopsis 0 Pass 0 Fail.9 g I Distance I Both I R I L;; ~ I I 201 I 201 I 201

I 0 Not testedI Test used:I

III

o Pass o Referred to eye doctor o Unable to test - needs rescreen

k> Summary of Findings (check one):... o Well child; no conditions identified of concern to school program activities'" o Conditions identified that are important to schooling or physical activity (complete sections below and/or explain here):~...0

"...'"U'" .:a Ql

=U =" 0.,

'0 .. _ Allergy 0 food: o insect: o medicine: o other:0 '"'5 il<

Type of allergic reaction: o anaphylaxis o local reaction Response required: 0 none o epi pen o other:rrJ =0'<;' :d _Individualized Health Care Plan needed (e.g., asthma, diabetes, seizure disorder, severe allergy, etc).. =~ '"> _ Restricted Activity Specify:B

..~., = _ Developmental Evaluation o Has IEP o Further evaluation needed for:= •...

0:d'" Medication. Child takes medicine for specific health condition(s). o Medication must be given and/or available at school.-e -='" _ Special Diet Specify:SS _ Special Needs Specify:0<.>

"p:: Other Comments:

Health Care Professional's Certification (Write legibly or stamp):

Name: Signature: Date: _1 __ 1_-

PracticelClinic Name: Address:

Phone: - - Fax: - - Email:------ ------

MCH 213 F revised 4/07 4