Language Leaders

Phone:
630-232-2001
Fax:
630-578-0948

Please mail your application to:

401 W. State St.
Geneva, IL.
60134

Young Leaders Bilingual Academy 2011/2012 Application

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:_________