ECS at BSO Registration

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Welcome to the Early Childhood School at B'nai Shalom of Olney!

To register your child for school at the ECS, please complete the entire form below. This enrollment form includes registration and digital releases needed for participation in the Early Childhood School. By filling in your name in the form below, you are providing a digital signature equal to signing a "hard copy" release for your child.

In addition to the form below, Maryland requires all preschool students to have an annual health assessment, updated immunization records, and a one-time lead test (for those required). Before your child can begin school at the ECS, these forms must be on file with the ECS office.

If your child has allergy or medical reasons that we may need to administer prescription medication at school, a Medical Conditions and Instructions Sheet and Medication Authorization Form, both completed and signed by your child's pediatrician, should be provided to the school along with any emergency medication needed before your child begins school.

Downloadable copies of all medical forms, as well as the ACH payment authorization form can be found here.

If you have any questions or concerns about this registration form or other ECS paperwork needed for enrollment, please call the school office at 301-570-0699.

* Enrollment Date

If enrollment date is "other," please explain

Please note that children starting after September 2019 will be charged one month's tuition to hold their place. This tuition is non-refundable after August 1, 2019 and will be applied to the final month's tuition payment for the school year.

* Child's First Name

Child's Middle Name

* Child's Last Name

* Child's Date of Birth

* Gender

If "Other" selected for gender, please explain

* Is your child a continuing ECS student?

* Please select school option:

Our Full Time 12-month program runs from mid-June through the end of the school year the following June. Our 10-month program runs from the beginning of school in late August through the end of the school-year in mid-June.

* How did you hear about the ECS?

* Would you like to sign up for early arrival?

* Would you like to sign up for Afternoon Programming (1pm-3pm)?

Afternoon Programming Option: 1:00pm to 3:00pm (member)

* Would you like to sign up for the Late Stay option (3pm-6pm)?

* Hours of Expected Attendance on Mondays (Please select all that apply)

* Hours of Expected Attendance on Tuesdays (Please select all that apply)

* Hours of Expected Attendance on Wednesdays (Please select all that apply)

* Hours of Expected Attendance Thursdays (Please select all that apply)

* Hours of Expected Attendance Fridays (Please select all that apply)

* For children in the 3s and 4s classes who stay until 3pm or later, please select one of the options below. If this preference changes at a later date, please email the ECS office to update your request.

Please Select OneMy child needs to be in a nap room, where they can sleep for two hoursMy child can be in a "rest" room where they rest or sleep for an hour and then have an hour of enrichmentN/A (My child is 2yrs old or leaves at 1pm)

* Child's Home Address (Street Number/name)

* Child's Address (City)

* Child's Address (State)

* Child's Address (Zip code)

* Does child have a parent/guardian living at a separate address?

Parent/Guardian Address: Please name the parent/guardian below who resides separately from your child and list their complete address. **If there is a divorce decree or custody arrangement that the school should be aware of, please submit copies of relevant documents to the ECS office. If there is a parent who does not have legal custody in your arrangement, please also schedule a time to speak with the ECS director about the legal agreement.**

* Parent/Guardian 1 First Name

* Parent/Guardian 1 Last Name

* Relatonship to child

Parent/Guardian 2 (If Applicable) First Name

Parent/Guardian 2 (If Applicable) Last Name

Relatonship to child

* Parent/Guardian 1 Home Phone

Parent/Guardian 2 (If Applicable) Home Phone

* Parent/Guardian 1 Cell Phone

Parent/Guardian 2 (If Applicable) Cell Phone

Parent/Guardian 1 Work Phone

Parent/Guardian 2 (If Applicable) Work Phone

* Parent/Guardian 1 Primary email

Parent/Guardian 2 (If Applicable) Primary Email

* Parent 1 Place of Employment and Occupation

Parent/Guardian 2 (If Applicable) Place of Employment and Occupation

* Is Parent 1 Jewish?

Is Parent/ Guardian 2 (If Applicable) Jewish?

* Please tell us who else lives in your household. For siblings, please list their names and ages.

* Please list languages spoken in your home

Additional Emergency Emails or Cell Phones

Please list any additional email addresses or cell phone numbers you wish to receive emergency notifications, including emails and text messages, such as unscheduled school closing information. Regular text message rates will apply to text messages received.

* Name of Child's Pediatrician

* Pediatrician's Address

* Pediatrician's Phone Number

Dismissal Authorization

Please fill in the name of the person(s) dropping off and picking up your child each day that he or she attends school. If you are the only person providing transportation, please indicate that below. To add or revoke dismissal authorization, please put the request in writing via email to the ECS director and office assistant. THIS DOCUMENT AUTHORIZES THE SCHOOL TO RELEASE YOUR CHILD TO THE INDICATED INDIVIDUAL(S) BELOW.

* Authorized Individual 1: First and Last Name

* Authorized Individual 1: Relationship to Child

* Authorized Individual 1: Cell Phone

* Authorized Individual 1: Full Address

Authorized Individual 2: First and Last Name

Authorized Individual 2: Relationship to Child

Authorized Individual 2: Cell Phone

Authorized Individual 2: Full Address

Authorized Individual 3: First and Last Name

Authorized Individual 3: Relationship to Child

Authorized Individual 3: Cell Phone

Authorized Individual 3: Full Address

Authorized Individual 4: First and Last Name

Authorized Individual 4: Relationship to Child

Authorized Individual 4: Cell Phone

Authorized Individual 4: Full Address

Emergency Contact when Parent/Guardian Cannot Be Reached

In the event that we cannot reach a parent/guardian in an emergency, please indicate a local contact we should call. The school will be authorized to release your child to this person.

* Emergency Contact: First and Last Name

* Emergency Contact: Relationship to Child

* Emergency Contact: Cell Phone

* Emergency Contact: Home Phone

* Emergency Contact: Work Phone

* Emergency Contact: Full Address

* I understand that in an EMERGENCY requiring immediate medical attention, my child will be taken to the NEAREST HOSPITAL EMERGENCY ROOM. My signature authorizes the responsible person at the ECS to have my child transported to that hospital.

I understand that in an EMERGENCY requiring immediate medical attention, my child will be taken to the NEAREST HOSPITAL EMERGENCY ROOM. My signature authorizes the responsible person at the ECS to have my child transported to that hospital.

* Name of Health Insurance Company

* Name of Policy Holder

* Relationship to Child

* Policy Number

* Does your child have any allergies?

Please Select OneYesNo

Please list any allergies your child has

Severity

My child's allergies do not require medication.My child's allergies sometimes require medication and we will be providing it to the school along with a medication authorization form completed by my child's pediatrician.My child's allergies are severe and potentially life threatening. We will provide medication to the school as well as an emergency plan for treatment completed by my child's pediatrician.

Please explain your child's symptoms and severity of reaction. Also indicate if you will keep emergency medication at the school.

Outdoor Play at ECS

Use of our "outdoor classroom" is an important part of the curriculum at the ECS. Children at the ECS play outdoors year-round, exploring their environment, learning about changes in seasons and weather, and developing an appreciation for the local ecology. Children may get wet and/or dirty during outdoor play. Please check the outdoor play releases below.

During the summer, ECS children engage in water play activities on the playground. If you are registering your child for our 12-month program, which includes the summer, please check the water play release below. (Children who enroll separately in camp will complete this release during their camp registration).

* Outdoor Play Permission Granted

Outdoor Play Permission Granted

I hereby grant permission to the ECS at BSO that my child has permission to participate in all outdoor play activities at school. I hereby understand that children will potentially be outdoors in rain and/or snow, and will be allowed to explore both mud and snow as part of their outdoor learning experience. I understand that I am expected to provide a complete change of clothes for my child, including socks and underwear, as well as weather appropriate attire, including rainboots and, in winter, hats, mittens/gloves, scarves, and snow boots daily. I hereby release and discharge the above, its assigns, and all persons acting under its permission or authority or those for whom it is acting, from and against any liability as a result of injury that may occur while the child is participating in outdoor play. I hereby warrant that I am of full age and competent to contract for the minor named below in so far as above is concerned. I have read the foregoing release and warrant that I fully understand the contents thereof.

* Water Play Permission Granted

Water Play Permission Granted

I hereby grant permission to the ECS at BSO that my child has permission to participate in all water activities (sprinklers, water tables, etc.) that will be held at the ECS. I hereby understand that water is splashed/sprayed on the children. I hereby release and discharge the above, its assigns, and all persons acting under its permission or authority or those for whom it is acting, from and against any liability as a result of injury that may occur while the child is participating in water play. I hereby warrant that I am of full age and competent to contract for the minor named below in so far as above is concerned. I have read the foregoing release and warrant that I fully understand the contents thereof.

Sunscreen/Ointment/Insect Repellent Permission: I hereby give the ECS permission to apply the non-prescription items selected below.

Sunscreen (For reapplication during Afternoon Enrichment or Late Stay)Ointment (Diaper cream/other)Insect Repellent

* I understand that I must provide the products I wish to be used on my child and that the school will not apply those provided for another child in the absence of one provided by me.

I understand that I must provide the products I wish to be used on my child and that the school will not apply those provided for another child in the absence of one provided by me.

* I understand that children must come to the ECS with sunscreen applied prior to arrival at the ECS each day.

I understand that children must come to the ECS with sunscreen applied prior to arrival at the ECS each day.

* School Directory

Emergency Evacuation Plan

We have established an emergency evacuation plan for our school. Hopefully, we will never need to implement this plan, but we want to make sure you are aware of this just in case we must evacuate the building and are unable to return. Our friends at St. John’s Episcopal Church next door to us at: 3247 Olney-Laytonsville Road will welcome your children and our teachers. Parents would be expected to pick their children up at St. John’s Episcopal Church as soon as they are notified about the emergency. Teachers will stay with your children at all times until you or someone listed on your carpool form arrives. Our backup evacuation is KinderCare across the street at 3805 Gelding Lane.

* We are aware of the Emergency Evacuation Plan of B’nai Shalom of Olney Nursery School. If the building needs to be evacuated, we agree to promptly pick our child/children up next door at St. John’s Episcopal Church: 3247 Olney-Laytonsville Road or the second pick-up site across the street at KinderCare at 3805 Gelding Lane.

We are aware of the Emergency Evacuation Plan of B’nai Shalom of Olney Nursery School. If the building needs to be evacuated, we agree to promptly pick our child/children up next door at St. John’s Episcopal Church: 3247 Olney-Laytonsville Road or the second pick-up site across the street at KinderCare at 3805 Gelding Lane.

Children with Special Needs

All children are welcome in our Early Childhood School. We do not discriminate based on race, color or national origin in the admission of our students. We do everything that is possible to accommodate all children in our program.

When we have a child that is having difficulty in our typical early childhood school classroom, we will consult with parents and as well as representatives from the Montgomery County Childcare Resource and Referral Service or other providers as requested by the parents. We will work exhaustively with parents, the Early Childhood School staff, and any support personnel hired by the parents (for example, educational consultants, physicians, physical therapists, occupational therapists, psychologists, etc.) to accommodate your child.

If it is decided that the child can be accommodated in our classroom with a trained support person providing one-on-one help for that child, it is hoped that the early childhood school program will continue for that child. Our affiliated agencies will provide training for our staff and consult with the parents and the professional staff the parents are using.

It needs to be understood by all parties involved that parents must pay for the additional support person in the classroom and for the training of that support person. The parents must also pay for consultations, testing and professional services. It would be expected that parents would work with the Early Childhood School staff to get the appropriate support help and be involved in the development and individual education plan for their child.

We will make every effort to work with you and your child. If, however, after exhaustive measures, we are not able to sustain a classroom environment for all of the children that is consistent with the Early Childhood School’s philosophy and goals, it may become necessary to find another program for your child.

* We have read the Early Childhood School at B’nai Shalom of Olney policy about children with special needs. We are aware of and will abide by the school’s policies.

We have read the Early Childhood School at B’nai Shalom of Olney policy about children with special needs. We are aware of and will abide by the school’s policies.

Parent Handbook

All families are required to read and abide by the Parent Handbook. Please click here to read the handbook.

* I have read the Early Childhood School at B’nai Shalom of Olney Parents’ Handbook. I am aware of the terms and policies set forth in the Parents’ Handbook and will follow and abide by these policies.

I have read the Early Childhood School at B’nai Shalom of Olney Parents’ Handbook. I am aware of the terms and policies set forth in the Parents’ Handbook and will follow and abide by these policies.

About My Child

In order for us to best meet your child's needs and your goals for their time with us at the ECS this year, please answer some questions about your child.

* My child likes to be called (nickname):

* Things my child does well:

* My child likes:

* My child dislikes:

* Things I am working on with my child:

* My child is comforted by...

* My child has difficulty with the following activities

* My goals for my child this year at the ECS are...

* Does your child have physical, speech, social, emotional or developmental differences?

If you child has had any developmental assessments, please provide a copy to the school office. If your child sees a developmental specialist, please list their names, field of work, and contact information below. By completing this form, you are giving us permission to speak with them about your child's needs.

Other things I want you to know (about our family, about my child, etc) that will help my child have a successful year

Please let us know if you or your family members have any special skills, interests, hobbies, or employment that the students at the ECS might be interested in. For example, if you are a doctor, and they are students are studying animals, they might be interested in x-rays of bones, etc.

If there are changes in your child's home environment (sick family member, divorce, move, death, etc.) please be in contact with us so we can best support your child and family.

I acknowledge understanding of the following ECS policies and agree to the terms defined in these policies:

Registration is considered completed only upon both the submission of the application and the receipt of the registration fee in full.
There is a prepayment of one month’s tuition which must be paid by August 7th each school year for 10-month students, and June 7th for 12-month students. This prepayment will then be credited toward the last month’s tuition for that school year. For those enrolling mid-year, the prepayment is due upon registration acceptance.
After August 7th, a sixty-day (60) notice must be submitted in writing if withdrawing during the school year. The tuition prepayment will then be credited to the final month of enrollment.
If at any time the Director of Early Childhood Education determines that the ECS cannot provide an appropriate program for a child, enrollment will be terminated and the prepayment will be applied to any outstanding balance. The remainder will be refunded.

* I accept the above terms (REQUIRED)

I accept the above terms (REQUIRED)

Non-Refundable Registration Fee: $250

* Registration Fee $250

Registration Fee $250

* Parent/Guardian 1: By typing your name in the box below, you verify that all of the information above is true and accurate to your knowledge. Further, you acknowledge that you have given permission or approved of all parts of this application form.

* Please enter the date you have signed this application

Parent/Guardian 2 (If Applicable): By typing your name in the box below, you verify that all of the information above is true and accurate to your knowledge. Further, you acknowledge that you have given permission or approved of all parts of this application form.

Please enter the date you have signed this application

Tue, May 21 2019 16 Iyyar 5779