Purpose Point Learning Academy Application Packet

PLEASE NOTE: THERE IS A $100 REGISTRATION FEE THAT MUST ACCOMPANY THIS APPLICATION. DISREGARD IF PAYMENT WAS SENT WITH YOUR WAITLIST FORM.

Please mail to:
4801 Hwy 58, Unit 105, Chattanooga, TN 37416
Ellwanda White, Director
Edward Cunningham, Asst. Director
Phone 423-541-9626

Enrollment Date(Required)

CHILD'S INFORMATION

Child's Full Name(Required)
First Last

Age(Required)

Child's Birthdate(Required)
MM slash DD slash YYYY

Child's Address(Required)
Street Address City State / Province / Region ZIP / Postal Code Country

FAMILY INFORMATION

Mother

Mother's Name
First Last

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

Mother's Phone (cell)

Mother's Phone (work)

Email Address

Mother's Employer

Employer Address
Street Address City State / Province / Region ZIP / Postal Code Country

Father

Father's Name
First Last

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

Father's Phone (cell)

Father's Phone (work)

Email Address

Father's Employer

Employer Address
Street Address City State / Province / Region ZIP / Postal Code Country

Salary Range (This information is required for our Donors. It is used for statistical purposes only)

Monthly income range. (Please check one)(Required)

$1,000-$2,499

$2,500-$3,499

$3,500-$4,499

$4,500-$5,499

$5,500-$6,499

$6,500-$7,499

$7,500-$8,499

$8,500-$9,499

$9,500-$10,499

THIS STATEMENT IS FOR SCHOOL AGED CHILDREN ONLY

My Child Attends

My Child's shot record is located at his/her school

Parent's Signature
First Last

Date
MM slash DD slash YYYY

The total fees for your child are due every week. Payments must be made on Friday or Monday before Services are rendered. Tuesday payments will have a late fee of $25.00. Forms of payment accepted: Cash, Money Order, checks, Debit/Credit cards. We do accept DHS certificates. Parents are responsible for any co-pay on the certificates.

Other household members:

MY CHILD IS AUTHORIZED TO BE DROPPED OFF BY, OR RELEASED TO:

Name
First Last

Phone

Relationship to child

Name
First Last

Phone

Relationship to child

Name
First Last

Phone

Relationship to child

Name
First Last

Phone

Relationship to child

Parent's Signature
First Last

PPLA WILL MAKE EVERY EFFORT TO KEEP EACH FAMILY INFORMED OF ALL ACTIVITIES, THEREFORE WE WILL HAVE 'PARENT MEETINGS'. WE WILL MAKE SURE THAT YOU ARE INFORMED AT LEAST A WEEK IN ADVANCE OF A PARENT MEETING. THANK YOU FOR TRUSTING US WITH YOUR MOST PRECIOUS GIFT.

PPLA CHILD HEALTH HISTORY/ASSESSMENT

Child's Name
First Last

Date of Birth
MM slash DD slash YYYY

Please check all that apply and list any health information needed to care for your child.

Pregnancy and Birth

1.) Were there any problems with pregnancy or your child's birth?
Yes
No

2.) Was his/her birth weight under 52 pounds?
Yes
No

3.) Did the baby have any problems in the hospital?
Yes
No

Medical Problems

4.) Has your child ever been in the hospital overnight?
Yes
No

5.) Is your child taking any medicine?
Yes
No

If yes, what

6.) Any allergies or reactions to medicine, DTP or other shots, or insects?
Yes
No

7.) Has your child had asthma or wheezing?
Yes
No

8.) Does your child have speech or hearing problems?
Yes
No

9.) Has your child had more than two ear infections in a year?
Yes
No

10) Has your child had tonsillitis?
Yes
No

11) Does your child have trouble with his/her eyes or seeing?
Yes
No

12) Has your child had a bladder or kidney infection?
Yes
No

13) Does he/she have burning when urinating?
Yes
No

14) Does he/she have seizures, fits or shaking spells?
Yes
No

15) Have you ever been told your child has a heart murmur?
Yes
No

16) Is your child able to play as hard as other children?
Yes
No

17) Has your child ever had a bumpy, swollen reaction to the TB skin test?
Yes
No

18) Has your child ever been with anyone having TB?
Yes
No

19) Has your child ever had worms?
Yes
No

20) Does your child scratch his/her genitals?
Yes
No

Is his/her bottom or genitals red or sore?
Yes
No

21) Is your child a hemophiliac(free bleeder)?
Yes
No

22) Is your child on a heart monitor?
Yes
No

23) Does your child have tubes in his/her ears?
Yes
No

General Development

24) Is your child in a special education program in school?
Yes
No

25) Does your child get along with other children?
Yes
No

26) Is he/she usually happy?
Yes
No

27) Does your child have any special problems not indicated above?
Yes
No

28) When did your child last see a doctor?

Any known allergies/sensitivities [Medications, Foods, Others]? If yes, please list:

Any chronic illness?
Yes
No

Or medical conditions?

Asthma, Diabetes, Seizures, Heart Problems, Other

Any Disabilities?

Hearing Impairment, Visual Impairment, Developmental Delay, Physical Impairment, Emotional Problems, Other

Please have physician documentation on any illness or disabilities.

Parent Signature
First Last

Date
MM slash DD slash YYYY

PPLA PERMISSION FOR HEALTHCARE

PURPOSE POINT LEARNING ACADEMY HAS PERMISSION TO SEEK EMERGENCY MEDICAL TREATMENT FOR MY CHILD. I WILL BE RESPONSIBLE FOR ANY AND ALL CHARGES ABOVE INSURANCE BENEFITS THAT ARE INCLUDED AS A RESULT OF THE MEDICAL TREATMENT FOR MY CHILD.

Parent/Guardian Signature
First Last

Date
MM slash DD slash YYYY

Child's Name
First Last

Date of Birth
MM slash DD slash YYYY

Child's Physician

Phone

Physician's Address
Street Address City State / Province / Region ZIP / Postal Code Country

AUTHORIZED ADULTS:

In the event of an emergency, please indicate your name and number and another authorized person that can be reached:

Parent/s Name/s

Phone

Another authorized person:

Phone

Another authorized person:

Phone

FIRST AID:

In the event of an emergency, I authorize the staff of Purpose Point Learning Academy to provide any first aid care deemed necessary for my child.

Signature
First Last

Date
MM slash DD slash YYYY

EMERGENCY CARE:

In the event of an emergency in which I cannot be reached, the physician listed above and the local hospital are hereby authorized to provide any emergency care deemed necessary for my child.

Signature
First Last

Date
MM slash DD slash YYYY

HEALTH RECORD TRANSFER:

In the event of an emergency, I hereby authorize the transfer of my child's health record to the local hospital.

Signature
First Last

Date
MM slash DD slash YYYY

Statement of Understanding and Agreement

I have read and understand the policies and procedures of Purpose Point Learning Academy in which I agree upon.
Yes

Parent's Signature
First Last

Date
MM slash DD slash YYYY

Purpose Point Learning Academy Requirement Notice:

1. I have received a summary of licensing requirements and a parent handbook.
2. I do hereby authorize emergency medical care to my children.
3. I understand Financial Requirements, Dress Code, toys, and late pick up policy.
4. I have toured the facility before enrolling my child.

Parent's Signature
First Last

Date
MM slash DD slash YYYY

PPLA STUDENT MEDIA CONSENT AND RELEASE FORM

Throughout the school year, students may be highlighted in efforts to promote Purpose Point Learning Academy activities and achievements. For example, students may be featured in materials to train teachers and/or increase public awareness of our schools through newspaper, radio, TV, the web, DVDS, displays, brochures, and other types of media.

I, as the parent/guardian of [type student's name below], hereby give Purpose Point Learning Academy and its employees permission to print, photograph, and record my child for use in audio, video, film, or any other electronic, digital, and printed media.

1. This is with the understanding fully aware that I will not receive monetary compensation for my child's participation.
2. I further release and relieve Purpose Point Learning Academy, its employees, and other representatives from any liabilities, known, or unknown, arising out of the use of this material.

I certify that I have read the Media Consent and Release Liability statement and fully understand its terms and conditions.

Student' Name
First Last

Parent's Signature
First Last

Date
MM slash DD slash YYYY

Approved April 26, 2021

INFANT SAFE SLEEP POLICY

I have been notified of the agency's safe sleep policy which is to lay infants down on their backs and to touch them every 15 minutes to ensure they are breathing.

Parent's Signature
First Last

Date
MM slash DD slash YYYY

Enter Your Email Below(Required)

Name
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