Registration Application - Independence Academy

Friends & Family Application

Program Options:(Required)

Please select all Programs that you are interested in:

After School Specials (beginning at 3pm):

Please select all Specials that you are interested in:

Spanish (3pm-4pm)

Art (3pm-4pm)

Soccer (3pm-4pm) (must be at least 4 years old)

Hip Hop (3pm-4pm)

Music (3pm-3:30pm)

STEM (3pm-4pm)

Dance (3pm-4pm)

American Sign Language (3pm-4pm)

German (3pm-4pm)

Child's Information

First Name:(Required)

Middle Name:

Last Name:(Required)

Date of Birth(Required)

Height & Weight:(Required)

Sex/Gender:(Required)

Male

Female

Home Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Parent/Guardian 1 Information

Name(Required)

First Last

Relationship to Child:(Required)

Email(Required)

Phone(Required)

Home Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Employer

Work Phone

Parent/Guardian 2 Information

Name(Required)

First Last

Relationship to Child:(Required)

Email(Required)

Phone(Required)

Home Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Employer

Work Phone

Emergency Contact 1

Each child is required to have an additional two emergency contacts. These are people we would reach out to if we are unable to reach a parent/guardian.

Name(Required)

First Last

Phone(Required)

Relationship to Child(Required)

Emergency Contact 2

Each child is required to have an additional two emergency contacts. These are people we would reach out to if we are unable to reach a parent/guardian.

Name(Required)

First Last

Phone(Required)

Relationship to Child(Required)

The below information helps us to understand the family dynamics.

Parent Status – Parents are:(Required)

Single

Married

Separated

Divorced

Other

Who is enrolling the child?(Required)

Parent/Guardian 1

Parent/Guardian 2

Other

If other, enrolling peron's name:

Who is responsible for payment?(Required)

Parent/Guardian 1

Parent/Guardian 2

Other

If other, responsible person's name:

Is there any legal paperwork pertaining to your child that we should be aware of? (This can include custody agreements, IEP paperwork, etc.)(Required)

Yes

If yes, please explain below:

Medical Information

Please be honest and as detailed as possible. This information will help us to be more informed on your child’s medical history and provide care to the best of our abilities. There may be additional documentation or training that we will need from you and/or your child’s physician.

Do you have any concerns about your child's development?(Required)

Yes

If yes, please explain. Also, let us know if you have spoken to your physician about your concerns and if you have had any screening/testing done (vision, hearing, speech, development, etc.)

Does your child currently have any limitations to physical activity?(Required)

Yes

If yes, please explain.

Does your child require any special equipment for daily activities?(Required)

Yes

If yes, please explain.

Has your child had any serious injuries or hospitalizations that we should be aware of?(Required)

Yes

If yes, please explain.

Does your child require medication or treatment every day or as needed?(Required)

Yes

If yes, please list the name of the medicine, dosage, how many times per day and time taken, and prescribing physician.

Does your child have any known allergies?(Required)

Yes

If yes, please explain and list any prescribed medications.

All About Me

Child Developmental Insights: We believe that you are your child’s first and most important teacher. We believe that education is a partnership between home and childcare/school. To begin this communication, please take some time to tell us a little about your child.

Child's Name(Required)

First Last

Child's Nickname/Preferred Name

Child lives with:(Required)

Primary Language spoken at home:(Required)

Other Languages spoken at home:

Holidays celebrated or significant cultural events:

Are there any recent traumatic situations the child has been exposed to recently, such as a death in the family, divorce, new sibling, etc.?

Are there other siblings/family in the home?(Required)

Yes

If yes, please list name(s) and age(s):

Has your child participated in a group care setting previously?(Required)

Yes

If yes, was it a childcare center or family childcare?

Do you have back up care arranged in case of illness or center closure?(Required)

Yes

Does your child sleep through the night?(Required)

Yes

Mostly

Sometimes

Does your child nap?(Required)

Yes

If yes, when/how often, and how long?

What time does your child typically go to bed at night and awaken in the morning?

Are there any dietary food restrictions?(Required)

Yes

If yes, please explain.

Can your child be relied upon to indicate bathroom wishes?(Required)

What words does your child use for Urination & Bowel Movements:(Required)

What is your child's favorite food?(Required)

What are your child's overall strengths?(Required)

My child feels confident when…(Required)

My child is afraid of… (Are there any fears we should be aware of?)(Required)

My child gets frustrated when…(Required)

When my child gets upset, she/he…(Required)

What is your normal method of discipline?(Required)

What is your child's temperament? Are they easy going, hard to please, demanding, aggressive, etc.(Required)

Has your child had experience playing with other children?(Required)

Does your child have any security objects (blanket, pacifier, bottle, toy, etc.)?(Required)

How do you soothe your child and/or how does your child self soothe?(Required)

What are your child's favorite hobbies, activities, toys, books, or games?(Required)

In most cases, when opportunities arise to make choices your child prefers to: (make a decision, shuts down with choices, etc.)(Required)

What are your child's physical capabilities (walking, running, climbing trees, cartwheels, etc.)?(Required)

If you can think of any other particular preferences that your child may have regarding environmental conditions, likes and dislikes (rain, water, etc.), please list them below:(Required)

What goals do you have for your child in school this year?(Required)

What expectations do you have for us, your child's teachers?(Required)

What is your preferred method of communication with your child's teacher? (email, app messaging, phone calls, etc.)(Required)

Are there any other comments or information you would like the center to know? Any specific concerns?

Inde Elementary & Home School Hangout

If you interested in the Inde Elementary or Home School Hangout program, please fill out the below section. If you are not interested in this program, please skip this section by scrolling to the bottom, and submit the application.

How does your child feel about being outside? Do they like it, tolerate it, dislike it, etc.

How is your child around animals? (excited, scared, aggressive, unsure, comfortable, etc.)

Did you child have prior schooling to now (public school, private school, home school)? If so, what was their school experience like? Do they like/dislike certain subjects more than others?

What subjects do you feel they need extra help with?