Early Childhood Program/Waiting List Application



Waiting List ApplicationPlease include the $20.00 Waiting List Application fee (This fee is non-refundable and non- transferable)Application Date: Childs Name FORMTEXT ?????Date of Birth FORMTEXT ?????ProgramCheck the appropriate program(s) and requested schedule informationFamilies requesting FULL TIME schedules are given priority on the waiting listMain CenterSchool AgeUPK Extension FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Requested ScheduleProgram(s)Full Time ProgramFull Time FORMCHECKBOX Before School FORMCHECKBOX Part Time M-W-F FORMCHECKBOX After School FORMCHECKBOX Part Time T-Th FORMCHECKBOX Holiday Program FORMCHECKBOX Parent Name FORMTEXT ?????Home Address FORMTEXT ?????City FORMTEXT ?????State FORMTEXT ??Zip Code FORMTEXT ?????Home Phone FORMTEXT ?????Cell Phone FORMTEXT ?????Work Phone FORMTEXT ?????E-Mail FORMTEXT ?????Affiliation(s) of either parent/guardian FORMCHECKBOX Sibling Already Enrolled in a CCCC ProgramName FORMTEXT ?????Program FORMTEXT ????? FORMCHECKBOX SUNY StudentCollege FORMTEXT ????? FORMCHECKBOX Faculty or Staff of SUNY FredoniaUnion FORMTEXT ????? FORMCHECKBOX Community MemberRequested start date: FORMTEXT ?????FOR OFFICE USE ONLYDate ReceivedFee PaidInitialsWaiting List Priority1. Students of SUNY Fredonia2. Students of SUNY System Schools3. SUNY Fredonia Faculty requesting FULL TIME care4. SUNY Fredonia Staff requesting FULL TIME care5. Community Members requesting FULL TIME care6. SUNY Fredonia Faculty requesting PART TIME care7. SUNY Fredonia Staff requesting PART TIME care8. Community Members requesting PART TIME care*Current Staff members are given first priority for enrollment of his or her own children when space is available. HEALTH DEVELOPMENT QUESTIONNAIREAnswers to the following questions assist the program to select the most appropriate setting for each child and support each family. Additional information may be requested to ensure the program is equipped to accommodate each child’s needs and provide the highest quality care possible.BIRTH (Answer if the child you want to enroll is less than 12 months of age)Child’s date of Birth: FORMTEXT ?????Due Date: FORMTEXT ?????Was the child born more than 3 weeks early or late? FORMCHECKBOX No FORMCHECKBOX YesWhat was the child’s birth weight? FORMTEXT ?????lbs FORMTEXT ?????ozWere there any concerns about the child at birth? Or shortly after? FORMCHECKBOX No FORMCHECKBOX Yes If yes, what? FORMTEXT ?????MEDICAL (Answer for all children)Does the child have any diagnosed allergies or allergic reactions? FORMCHECKBOX No FORMCHECKBOX Yes If yes, what? FORMTEXT ?????Does the child have any dietary restrictions? FORMCHECKBOX No FORMCHECKBOX Yes If yes, what? FORMTEXT ?????Does the child have any diagnosed medical conditions? (Examples: diabetes, heart condition, severe asthma)? FORMCHECKBOX No FORMCHECKBOX Yes If yes, what? FORMTEXT ?????Does the medical condition affect the child’s daily activities? FORMCHECKBOX No FORMCHECKBOX Yes If yes, how? FORMTEXT ?????Has the child ever had a serious accident or illness (Examples: broken bones, head injuries , burns, poisoning, RSV)? FORMCHECKBOX No FORMCHECKBOX Yes If yes, what? FORMTEXT ?????Is your child up to date on all immunizations? FORMCHECKBOX No FORMCHECKBOX YesIf no, explain. FORMTEXT ?????DEVELOPMENTAL (Answer for all children)Do you have any concerns about the child’s development? FORMCHECKBOX No FORMCHECKBOX Yes If yes, what? FORMTEXT ?????Has a medical professional expressed a concern about the child’s development? FORMCHECKBOX No FORMCHECKBOX Yes If yes, what? FORMTEXT ?????Do you have any concerns about the child’s speech\language development? FORMCHECKBOX No FORMCHECKBOX YesCan you understand the child? FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX N\ACan other people understand the child? FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX N\ADoes the child relate well (play, share toys) with other children? FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX N\AIs the child receiving services from Early Intervention or Preschool Special Education (speech, occupational or physical therapy) FORMCHECKBOX No FORMCHECKBOX Yes If yes, what? FORMTEXT ????? ................
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