Enrollment Application

Please select the location that you wish to enroll your child

4115 Jacksol Drive, San Jose

831 Malone Road, San Jose

Program Enrollment (Please select one)

Full Day w/ Extended Care (5 days per week, before 8am and/or after 5pm)

Half Day (5 days per week, 8am-12:00pm)

Full Day (5 days per week, 8am-5pm)

Half Day x4 (4 days per week, 8am-12:00pm)

Full Day x4 (4 days per week, 8am-5pm)

Half Day x3 (3 days per week, 8am-12:00pm)

Full Day x3 (3 days per week, 8am-5pm)

Child’s Information

Child’s First & Last Name Date of Birth Child’s Address City State Zip Male Female Preferred Start Date Name of School Child Previously Attended

First Parent/Guardian Information

Full Name Relationship to Child Home Address City State Zip Place Employed Business Phone Extension Home Phone Cell Phone Email address

Second Parent/Guardian Information

Full Name Relationship to Child Home Address City State Zip Place Employed Business Phone Extension Home Phone Cell Phone Email address

Person(s) or Agency that has legal Custody of Child (if applicable) Phone # for party with legal custody (if different from parent)

Emergency Information

Allergies or Intolerance to Food, Medication and/or other Special Needs Child’s Physician Phone #

Names, Addresses and Phone Numbers of two (2) people to contact if parents CANNOT be reached

Name1 Phone # Address City State Zip

Name2 Phone # Address City State Zip

Person(s) Authorized to Pick Up Child Person(s) NOT Authorized to Pick Up Child If a parent is not allowed to pick up the child, please attach a copy of appropriate custody papers. (choose file) How Did You Find Out About Us?

Attach legal documents (Optional)

Application Fees

For this application to be processed, a $40 application fee must be paid. A payment link will be emailed to you within 24 hours after on-line submittal.

Agreements

1. Learning Pathways agrees to notify the parent/guardian whenever the child becomes ill and the parent/guardian will arrange to have the child picked up as soon as possible if so requested by the center.

2. The parent/guardian authorizes Learning Pathways to obtain immediate medical care if any emergency occurs when he/she cannot be located immediately.*

NOTE: If there is an objection to seeking emergency care, a statement should be obtained from the parents or guardian that states their objection and the reason for their objection.
3. The parent/guardian agrees to Learning Pathways’ rules and regulations as described in the policy guidelines found in the Parent Handbook (provided).

4. The parent/guardian agrees to inform Learning Pathways within 24 hours or the next business day after his/her child or any member of the immediate household has developed a reportable communicable disease, as defined by the State Board of Health, except for life threatening diseases, which must be reported immediately.

Proof of the child’s identity and age may include a certified copy of the child’s birth certificate, birth registration card, notification of birth (hospital, physician or midwife record), a passport, a copy of the placement agreement or other proof of the child’s identity from a child placing agency or a certification by a director of a school in the U.S. that a certified copy of the child’s birth record that was previously presented. While Learning Pathways is not required to keep proof of the child’s identity, documentation of viewing this information must be maintained for each child.