Imagine Nation Academy Registration 2023-2024


The Commonwealth of Massachusetts
Department of Early Education and Care
Child’s Enrollment Form


Child Information

Child’s Name:   Date of Birth:
Age at Admission: Date of Admission: Fall 2023
Child’s Home Address:
Home Phone Number:
Primary Language:   Identifying Marks:
Eye Color: Hair Color:   Skin Color:
Sex: Height: Weight:

 

Please upload a headshot image of your child:

Parent/Guardian Information

Parent/Guardian Name:
Relationship to Child:
Home Address:
Reachable Phone Number:
Email Address:
Business Name:
Business Address:
Business Phone Number:
Hours at Work:  

Parent/Guardian Name:
Relationship to Child:
Home Address:
Reachable Phone Number:
Email Address:
Business Name:
Business Address:
Business Phone Number:
Hours at Work:

Additional Information

Child’s Physician:
Address: Phone Number:
Allergies/Special Diets?
Individual Health Plan for child with a chronic health condition? If yes, please attach.


Copies of any custody agreements, court orders, and restraining orders pertaining to the child? If yes, please attach.

Special limitations or concerns?

School Age Only

Current School:
School Address: School Phone Number:

I certify that documentation of physical examination and immunizations in accordance with public school health requirements and lead poisoning screening in accordance with public health requirements are on file at my child’s school.

Parent/Guardian initials: Date:

EMERGENCY CARD INFORMATION

Child's Name: Date of Birth:
Child's Home Address: Phone:

 

INSTRUCTIONS TO REACH PARENT/GUARDIAN

(Name, Address, Phone #)

      2.

(Name, Address, Phone #)

PEDIATRICIAN OR SOURCE OF HEALTH CARE

(Doctor's Name, Address, Phone#)

EMERGENCY CONTACT PERSON(S)

      1.

(Name, Address, Phone #)

      2.

(Name, Address, Phone #)

MEDICAL EMERGENCY TREATMENT

I hereby give Imagine Nation Academy permission to administer basic first aid and/or CPR to my child (Name) and/or take my child , to a hospital for medical treatment when I cannot be reached or when delay would be dangerous to my child's health.

 

INSURANCE INFORMATION (OPTIONAL)

Company Name:

Policy #

Participating Hospital:

Special Instructions:

THE COMMONWEALTH OF MASSACHUSETTS

Department of Early Education and Care

FIRST AID AND EMERGENCY MEDICAL CARE CONSENT FORM

Child's Name:  Date of Birth: 

 

I authorize staff in the childcare program who are trained in the basics of first aid/CPR to give my child first aid/CPR when appropriate. I understand that every effort will be made to contact me in the event of an emergency requiring medical attention for my child. However, if I cannot be reached, I hereby authorize the program to transport my child to the nearest medical care facility and/or to , and to secure necessary medical treatment for my child.

 

Child's Physician Name:

Address:

Phone Number:

 

Child's Allergies:

Chronic Health Conditions:

 

Emergency Contacts (In order to be contacted)

Name:

Address:

Relationship to child:

Home Phone: Cell Phone:

Do you give permission for child to be released to this person?:

 

Name:

Address:

Relationship to child:

Home Phone: Cell Phone:

Do you give permission for child to be released to this person?:

 

Name:

Address:

Relationship to child:

Home Phone: Cell Phone:

Do you give permission for child to be released to this person?:

 

Parent /Guardian Initials: Date (valid for one year):

 

 

Health Insurance Coverage: Policy #:

Parent/Guardian Name: Phone Cell

Parent/Guardian Name: Phone Cell

Commonwealth of Massachusetts

Department of Early Education and Care

MEDICATION CONSENT FORM 606 CMR 7.11(2)(b)

Name of child:

Please choose of the following:

 		  
 

 

My child has previously taken this medication:

 

My child has not previously taken this medication, but this is an emergency medication and I give permission for staff to give this medication to my child in accordance with his/her individual health care plan:

 

If your child has an individual health care plan please upload it below.

I, , (parent or guardian) gives permission to authorize Imagine Nation Academy staff to administer medication to my child as indicated above and in the attached individual health care plan (if applicable).

Parent/Guardian Initials Date:

Imagine Nation Academy

Schedule Agreement

2023-2024 School Year

Child’s Name:

Grade level (entering)

AM

PM

 

Please check activities your child may be interested in participating in:

 

Please be aware that given the number of students attending the program that your child will only able to attend Early Release Days on the days that they are already in attendance.

 

THE COMMONWEALTH OF MASSACHUSETTS

Department of Early Education and Care

Small Group and Large Group Transportation Plan and Authorization

CHILD’S NAME:

MY CHILD WILL ARRIVE AT THE PROGRAM: MY CHILD WILL DEPART FROM THE PROGRAM:

 

CHILD’S NAME:

MY CHILD WILL ARRIVE AT THE PROGRAM: MY CHILD WILL DEPART FROM THE PROGRAM:

 

PARENT /GUARDIAN INITIALS: DATE:

REFER TO FIRST AID AND EMERGENCY MEDICAL CARE CONSENT FORM FOR RELEASE INFORMATION

Please review and initial the following statements. If you do not consent do not initial.

I have reviewed and understand the policies and procedures stated in the Imagine Nation Academy Parent Handbook for the 2023-2024 school year.

  Date:

I give my child permission to participate in supervised outdoor activities.

  Date:

I give my child permission to participate in gym activities.

  Date:

I give my permission for my child to be photographed/video taped for Social media.

  Date:

Imagine Nation Academy
Tuition Rates
2022-2023 School Year

Number of days attending Session 1 Day 2 Day 3-5 Days
AM 20.07 18.24 16.41
PM 29.17 26.74 23.10
AM/PM 49.24 44.98 39.51

 

  • There is a $75 nonrefundable annual registration fee due at the time of registration for the before and after care for BBES, WES and AMS.
  • Tuition is due by the Friday prior to the week of service
  • Tuition payments must be made through Procare only at this time. INA does not
    accept checks and any other payment arrangements must be made through the Director.
  • We are unable to offer sibling discounts at this time
  • There is a $25.00 late payment fee. Payment is considered late if not received by the Friday prior to service.
  • $25.00 charge for each schedule change made after initial schedule has been submitted.
  • $5.00 a minute late pick up charge to be paid to staff covering shift. Please pay staff directly.
  • Per Parent/Guardian Handbook you must pay when your child is absent. This includes COVID/Contact Tracing absences.

I have received, understood, and agree to abide by the INA tuition Schedule for the 2023-2024 school year.

Date:

Leave this empty:

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Document name: Imagine Nation Academy Registration 2023-2024
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March 27, 2023 11:02 am EDT Imagine Nation Academy Registration 2023-2024 Uploaded by Paige Reynolds - paigereynolds@imaginenationacademy.com IP 24.91.186.244
May 1, 2023 9:49 am EDT Document owner webmaster@imaginenationacademy.com has handed over this document to paigereynolds@imaginenationacademy.com 2023-05-01 09:49:25 - 168.122.75.109
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