Rayner Learning Center Application for Enrollment - Form - Unified Jewish Congregation of Baton Rouge

Rayner offers a full day, 5 days a week, program between the hours of 7:30AM and 5:30PM.
You will be required to submit a $25.00 application fee (plus a $0.93 service fee) to submit this application.
Please give us a call at 225-924-6772 with any questions!

Child's Information

Child's First Name

Child's Last Name

Known As (or nick name)

Child's Date of Birth

or anticipated date of birth

Child's Sex

Person(s) with Legal Custody of the Child

If applicable, court documents of custody agreements must be provided to the Rayner Learning Center

Sibling Information

Sibling Name

Sibling Age

Sibling Sex

Sibling Name

Sibling Age

Sibling Sex

Sibling Name

Sibling Age

Sibling Sex

Primary Address

Address

Address Line 2

City

State

Parent Information

Parent 1 First Name

Last Name

Email Address

Cell Phone Number

Home Phone Number

Work Phone Number

Employeer

Occupation

Parent 2 First Name

Last Name

Email Address

Cell Phone Number

Home Phone Number

Work Phone Number

Address if different than primary address

Religious Affliliation

Is your family a member of the Unified Jewish Congregation of Baton Rouge?

YesNoUJCBR members receive a $100 monthly discount on tuition and enrollment priority

Emergency Contact Information
- and -
Individuals Permitted to Pick-up Child

In the event of an emergency where neither parent is reachable, please contact:

Contact 1: First and Last Name

Relationship

Phone Number

The above Emergency Contact is permitted to pick up my child:

Contact 2: First and Last Name

Relationship

Phone Number

The above Emergency Contact is permitted to pick up my child:

Contact 3: First and Last Name

Relationship

Phone Number

The above Emergency Contact is permitted to pick up my child:

The following people, in addition to those indication above have permission to pick up my child.

First and Last Name

Relationship

Phone Number

First and Last Name

Relationship

Phone Number

First and Last Name

Relationship

Phone Number

The following person(s) DO NOT have permission to pick up my child:

I understand that if the name does not appear on this list, my child will not be released from school. Further, I understand that I will need to give written permission if my child is to go home with someone other than these designated persons.

Signature - First and Last Name

By typing your name, you understand and agree to the above statement.

Date

Medical Information and Permissions

Child's Pediatrician

Phone Number

Preferred Hospital

Child's/Family Dentist

Dentist Phone Number

Does your child have any condition which would limit their participation in the physical education program

NoYes

If yes, please describe:

Past serious injuries:

Past serious illnesses or hospitalization:

Is your child taking any medications?

NoYes

If yes, please list:

Allergies

Foods:

Medications:

Insects:

Other:

Does your child require an Epi-Pen?

NoYes

If yes, please describe the allergy that requires Epi-Pen use:

IMMUNIZATIONS: Please email or drop off a copy of your child's immunizations records to complete the application. You can email records to DirectorRLC@ujcbr.org.

First Aid and Emergency Permissions

I give Alfred G. Rayner Learning Center Staff permission to administer first aid to my child. In case of an emergency, the school staff promptly contacts the parents.I hereby give permission to the school staff to call 911 and/or transport my child as named above to the nearest emergency room if they deem it necessary or if they are unable to reach me or my designated emergency contact.

Signature - First and Last Name

By typing your name, you are providing your electronic signature to the Rayner Learning Center

Date

Allergy Notification Permission

I give permission to have my child’s photograph and allergy listed on our allergy list in the classroom.

Signature - First and Last Name

By typing your name, you are providing your electronic signature to the Rayner Learning Center

Date

Directory Permision

I give permission to have our address, phone number(s), and e-mail addresses listed in the School Directory. Please note below if names, address or phone should read other than that already on the application.I DO NOT give permission to have our address, phone number(s), and e-mail addresses listed in the School Directory

Directory information if different than already provided within this application

Signature - First and Last Name

By typing your name, you are providing your electronic signature to the Rayner Learning Center

Date

Permission to Photograph

On occasion, we may film or photograph events at the Rayner Center for social media or marketing materials. Likewise, the newspaper and television stations sometimes cover events taking place here. It is the Rayner Center’s policy not to release the names of children who are photographed to the media. However, we recognize that some parents do not wish for their children’s picture to appear in the newspaper or promotional materials for the school. Therefore, we are asking that all parents sign a release allowing their children to appear in such promotional pictures. If you would prefer that your child not appear is such film or photographs, please let us know. We will make every effort to ensure that your child does not appear in film or photographs of any events at the Rayner Center.

I give permission for my child to appear in film or photographs promoting the Rayner Learning Center or events covered by the local media. I agree to hold the Rayner Learning Center and the Unified Jewish Congregation of Baton Rouge harmless for the releaI DO NOT give permission for my child to appear in film or photographs promoting the Rayner Learning Center or events covered by the local media. I agree to hold the Rayner Learning Center and the Unified Jewish Congregation of Baton Rouge harmless for th

Signature - First and Last Name

By typing your name, you are providing your electronic signature to the Rayner Learning Center

Date

Water Activities Permission

Water activities include but are not limited to: Sprinkler Play and Indoor Water Activities such as Sensory Table. Water activities take place in the center or on the center grounds.

I give my permission for my child to participate in all water activities planned by the center. This permission will be valid for the duration of my child’s enrollment in the Rayner Learning Center.I DO NOT give my permission for my child to participate in all water activities planned by the center. This permission will be valid for the duration of my child’s enrollment in the Rayner Learning Center.

Signature - First and Last Name

By typing your name, you are providing your electronic signature to the Rayner Learning Center

Date

Diaper Cream Application Permission

The Alfred G. Rayner Learning Center has my permission to apply diaper cream to my child as they deem necessary. This permission will be in effect until I withdraw my child from the preschool program or until I notify the school in writing of any changes.The Alfred G. Rayner Learning Center DOES NOT have my permission to apply diaper cream to my child as they deem necessary. This permission will be in effect until I withdraw my child from the preschool program or until I notify the school in writing of an

Signature - First and Last Name

By typing your name, you are providing your electronic signature to the Rayner Learning Center

Date

Application Registration Fee

Application Registration FeeI am submitting an application fro enrollment. My application is not complete until the application fee has been paid and I have submitted immunization records to Latonia Douglas, Director.

Total Amount Due with Submission