Bilingual Nest, 300 Manhattan Ave., New York, NY 10026

APPLICATION: ONE-TIME FAMILY FEE: $200.00

Academic Year (YYYY / YYYY)

What would be your ideal start date?

Program

Infant (Spanish ONLY)
Toddler (Circle French OR Spanish)
Preschool (Circle Spanish OR French)

Child's Name

Date of Birth

Place of Birth

Sex

Age on September 1

Street Address

City

Zip Code

Guardian 1

Mother

Father

First and Last Name

Cell Number

Email Address

Employer

Business Number

Home Phone Number

Guardian 2

Mother

Father

First and Last Name

Cell Number

Email Address

Employer

Business Number

Home Phone Number

Does your child speak Spanish or French?

Yes

Do parents speak Spanish or French?

Yes

If parents are not at same address, who should we address correspondence to?

In case of Emergency name of relative or friend who can be called if we are unable to reach you:

Name

Telephone

Street Address

City

Zip Code

Emergency Doctor's Name

Emergency Doctor's Phone

September - June

Full Day (Monday through Friday): 8:00 am - 3:00 pm
Three Days (Monday, Wednesday & Friday): 8:00 am - 3:00 pm
Two Days (Tuesday & Thursday): 8:00 am - 3:00 pm
Enrichment: 3:00 pm - 6:00 pm:

Medical Statements and Consent

Bilingual Nest LLC is not permitted to administer any medication, if needed, please do so at home or after school.

I (we) authorize staff and Director of Bilingual Nest LLC to obtain all necessary Emergency Medical treatment, in case of an emergency?

Parent Initials

Do you authorize staff and Director of Bilingual Nest LLC to administer all necessary First Aid care for your child, if necessary?

Yes No

Parent Initials

List any allergies your child has, or medical conditions, seizures, asthma, handicap, he/she has

Note: All allergies/medical conditions must be stated on the child's medical form. Additionally, a "Standing Order" from the Pediatrician will be required in order to administer an Epi-Pen, Benadryl, or any Asthma medication. Your child will not be admitted without it.

Does your child has any disability?

Yes No

If yes, Please Specify

Does your child has speech delay?

Yes No

If yes, Please Specify

New York department of health requires that all children are vaccinated for school entrance.

Do you vaccinate your child?

Yes No

I, hereby, authorize Bilingual Nest LLC to provide care for my child.

I declare to the best of my knowledge that all statements made in this application are true.

First and Last Name (Guardian 1)

First and Last Name (Guardian 2)

Date

Amount

Payment For

Card Number

Name on Card

Expiry Date

Security Code

Total: