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Phone: 630-232-2001 Fax: 630-578-0948
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Young Leaders Bilingual Academy 2011/2012 Application
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Upon submission of this packet please provide:
· Student’s original birth certificate or copy
· Proof of immunization or exemption form immunization
· Completed enrollment form and registration fee
Legal Name of Student:______________________________________DOB_______
Last School attended:__________________________Grade completed:__________
Social Security Number:_________________________________________________
Address:__________________________________City:______________Zip:______
Gender (circle): Male Female
Name of Parent(s):_____________________________________________________
Email Address:__________________________________@_____________._______
Home Phone:_________________________________________________________
Cell Phone #1:________________________________________________________ Cell Phone # 2:________________________________________________________
Emergency Contact Person:______________________________________________
Relationship to Student:_________________________________________________
Emergency Contact Home Phone:_________________________________________
Emergency Contact Cell Phone:___________________________________________
Students Health Information
Physician:_____________________________________________________________________
Physician Address:______________________________________________________________
Physician Phone:________________________________________________________________
Dentist :_______________________________________________________________________
Dentist Address:________________________________________________________________
Dentist Phone:__________________________________________________________________
Vision
Known eye condition (other than corrective lenses)_____
Wears glasses _____ Worn at all times _____
Wears contact lenses _____ Worn at all times _____
Hearing
Known hearing problem _____ Uses hearing aid _____ Has tubes in ears _____
Allergies
Food _____ Environment _____ Medicine _____
Comments: ____________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Student has the following conditions:
Does medication need to be administered during school hours? Yes No
Please provide a signed Physician’s Authorization for Medication in School form
Condition medication prescribed by doctor dosage times to administer
_____ Asthma ___________________________ __________ ________________
_____ Epilepsy ___________________________ __________ ________________
_____ Fainting Spells ___________________________ __________ ___________
_____ Diabetes ___________________________ __________ ________________
Young Leaders General Permission Slip
As part of the education process at Young Leaders Academy, students will be participating in Out-of-class projects, going to museums, conferences, galleries, convocations, doing science field observations and engaging in many other related activities.
This permission slip is for all such trips that take place during the regularly scheduled academic day and that are part of the Young Leaders curriculum.
By signing this form you are giving your general permission for your child to engage in those activities that occur as part of the experiential education component of Young Leaders.
_______________________________________________________________________________
Parent Signature and Date
Registration Fee: A non refundable registration/material fee of $300 is due upon registration.
Tuition: check the program for which you are registering *Obtain up to $1400 credit toward your child's annual tuition through the "Wrigley Rooftop for Education" program.
PreK 3 Program _____Yearly tuition for 3 days/week program (M, W, F): $2163 or $225/mo. Aug - May via Autopay _____Yearly tuition for 5 days/week program (M-F): $3696 or $380/mo. Aug - May via Autopay
PreK 4 Program _____Yearly tuition for 3 days/week program (M, W, F): $2600 or $280/ mo. Aug - May via Autopay _____Yearly tuition for 5 day/week program (M-F): $4480 or $468/mo. Aug - May via Autopay
Kindergarten Program _____Yearly Tuition: $4480 or $468/mo. Aug - May via Autopay First - Fifth Grade Program _____Yearly Tuition: $6160 or $636/mo. Aug - May via Autopay Lunch _______ My child will bring their lunch from home. _______I would like my child to receive lunch at school ($480 for the year.) Our organic lunches contain 100% natural ingredients with no additives, preservatives, or chemicals of any kind.
Please make your check payable to Language Leaders.
Autopay (Tuition is broken down into 10 equal monthly payments) I would like to sign up for Autopay and have my credit card charged on the 1st of each month. ________________________________________
Signature
Visa Cardholder Name:________________________________________________________________
Card Number:_________________________________________________________exp date:_______
Signature:____________________________________________________________Amount:_________ |
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