Miss Shelleys UPWARD PREP School

66 Nassau Road, P.O. Box 487

Roosevelt, New York 11575
TEL# 516-378-9206 FAX# 516-378-9208

STUDENT APPLICATION
Please print or type.

Section 1 STUDENT

STUDENTS LAST NAME___________________________ FIRST NAME___________________________ MI________

DATE OF BIRTH__________ BIRTHPLACE (City; State, OR Country)______________________________ SEX_______
ADDRESS__________________________ CITY/TOWN_______________________STATE_________ ZIP____________
HOME TELEPHONE _______ __________

SOCIAL SECURITY#________________________
Section 2 MOTHER
MOTHERS LAST NAME _________________________ FIRST NAME_____________________________ MI_________

HOME ADDRESS (if different)______________________ CITY/TOWN _________________ STATE______ ZIP__________

HOME TELEPHONE ______________ _________

EMAIL:____________________________________

EMPLOYER _________________________ OCCUPATION _________________ BUSINESS TEL _______________

BUSINESS ADDRESS_______________________ CITY/TOWN ___________________ STATE ________ ZIP ___________
Section 3 FATHER
FATHERS LAST NAME _________________________ FIRST NAME_____________________________ MI_________
HOME ADDRESS (if different)______________________ CITY/TOWN _________________ STATE______ ZIP__________
HOME TELEPHONE ________ _________

EMAIL:____________________________________

EMPLOYER _________________________ OCCUPATION _________________ BUSINESS TEL _____ _________

BUSINESS ADDRESS_______________________ CITY/TOWN ___________________ STATE ________ ZIP ___________
Section 4 EMERGENCY CONTACT PERSON (other than parents listed above)
LAST NAME _________________FIRST NAME_____________________ RELATIONSHIP TO CHILD __________________
HOME ADDRESS_________________________ CITY/TOWN ____________________ STATE________ ZIP____________
HOME TELEPHONE:)________ _________

BUSINESS TEL: (

) ______ - _________

Section 5 SAFE PICK UP AUTHORIZATIONS

Only the following three (3) parents/guardians/adults are authorized to pick-up my child from MSUP campus.
1.

Last Name____________________ First Name_________________________ Phone_____________________

Address_________________________________ Relationship to child_________________________________

2.

Last Name____________________ First Name_________________________ Phone_____________________

Address_________________________________ Relationship to child_________________________________

3.

Last Name____________________ First Name_________________________ Phone_____________________

Address__________________________________ Relationship to child_________________________________

STUDENT APPLICATION
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LAST NAME___________________________ FIRST__________________

Section 6 CHILD CARE PROVIDER OR SCHOOL REFERENCES

Please list the three most recent child care providers who cared for your child or schools where they were in
attendance for the past two (2) years:
CHILD CARE PROVIDER/SCHOOL________________________________________________________________
ADDRESS__________________________________________________ TEL#
DATES OF ATTENDANCE___/___/___ to___/___/____REASON FOR LIVING______________________________
CHILD CARE PROVIDER/SCHOOL________________________________________________________________
ADDRESS__________________________________________________ TEL#(

)_________-______________

DATES OF ATTENDANCE___/___/___ to___/___/____REASON FOR LIVING______________________________

CHILD CARE PROVIDER/SCHOOL________________________________________________________________
ADDRESS__________________________________________________ TEL#(

)_________-______________

DATES OF ATTENDANCE___/___/___ to___/___/____REASON FOR LIVING______________________________

Section 7 FOR SACC STUDENTS ONLY
SCHOOL OF ATTENDANCE__________________________ GRADE_____ TEACHER________________________
SCHOOL ADDRESS______________________________

TEL# (

)_________---______________________

DAILY WEEKDAY SCHEDULE School Opening Time_____:______ A.M. School Closing Time ______:_____P.M.
TRANSPORTATION FROM MSUP TO SCHOOL (In morning) ____walk _____ school bus ____other(specify)________________
TRANSPORTATION FROM SCHOOL TO MSUP (In afternoon) ____walk _____ school bus ____other(specify)_______________
TRANSPORTATION FROM MSUP TO HOME (In evening)

____walk _____ school bus ____other(specify)________________

Is student authorized for INDEPENDENT DISMISSAL? ____ Yes ____ No If YES, at what times_______:_____A.M. ______:______P.M.

Section 8 HEALTH QUESTIONAIRE (To be completed by parent/guardian)

YES

NO

Is student currently undergoing medical, psychological, physical, or other TREATMENT or Therapy ?

Is the student currently taking any MEDICATION?

Does the student have any know ALLERGIES, ASTHMA, HAY FEVER, OR BRONCHITIS?
Has the student undergone any OPERATIONS?
Has the child suffered any ILLNESSES INJURIES, or other TRAUMAS which could affect performances?
Explain all YES responses in detail in the space provided below in
Section 9-Additional Information
The following additional information explains YES responses to the Health Questionnaire section above or is important and
should be considered by the administration and/or faculty (continue on back if necessary) ____________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________

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LAST NAME___________________________ FIRST__________________

Section 10 SCHOOL ACTIVITIES PERMISSION

I hereby grant permission for my child____________________ to use all of the play and recreational equipment
available through the school, and participate in all school activities, and to leave the school campus under the
supervision of authorized staff members for neighborhood walks and field trips. I will not hold Miss Shelleys
UPWARD PREP, Inc. liable for any injuries, which might be sustained in the course of said activities.
Parents/Guardians Signature__________________________ Date ________/________/ ________
Section 11 EMERGENCY MEDICAL AUTHORIZATION AND RELEASE FORM
I hereby grant permission to the school administrator, nurse, or their designee to take whatever reasonable steps
may be necessary to obtain emergency medical care for my child____________________. These steps may
include, but not limited to the following:
1. Attempt to contact parent, guardian, or listed emergency contact person (As per page 1 of this
Student Application).
2. If we cannot contact parent, guardian, or listed emergency contact person, we will do one or both of
the following until one of the aforementioned parent, guardians, or listed emergency contact person
is contacted:
(a) Call an emergency services ambulance unit:
(b) Have the child transported by ambulance to an emergency hospital in the company of a
designated staff member.
Furthermore, as the parent/guardian of aforementioned minor child, in the event none of the parents, guardians,
or listed emergency contact persons can be contacted, I authorize the Miss Shelleys Upward Prep, Inc.
designated staff member into whose care the above-named minor child has been entrusted, to consent to any xray, examination, anesthetic, medical, or surgical diagnostic procedure; medical or surgical treatment; or hospital
care to be rendered to said minor child upon advice of physician.
Finally, in the event none of the parents, guardians, or listed emergency contact persons is contacted, I authorize
Miss Shelleys Upward Prep, Inc. to have the above-named minor child released into the custody of its designated
staff member, should hospital care no longer be required.
This form is limited for use only in serious emergency situation, when parents, guardians, or listed emergency
contact persons cannot be contacted. The school will not be liable for any consequences resulted from false,
incorrect, or omitted information.
Parents Signature______________________________________ Date _________/ ________/__________
Witness: Signature______________________________________ Date ________/ ________/ __________
Section 12 AGREEMENT & ATTENTION
I have received, read, and understand the Miss Shelleys Upward Prep School Parent Information Handbook and
Application Package. I agree to abide by all policies including, but not limited to Tuition & Fees; Parent
Participation & Volunteering; Dress Code, Calendar, Curriculum; Field Trips: Emergency Medical Authorization,
etc. The information included on these applications forms is complete and true to the best of my knowledge.
Parents/Guardians Signature_________________________________ Date________/________/ ________

Childs Name_________________________________

TUITION POLICY
As a parent of Miss Shelleys Upward Prep/MSUP Elementary School, I am
aware that tuition is payable by the 1st of each month for the current month.
Tuition is payable whether my child attends school or not.
My monthly tuition is $_________________. Again, I am responsible for the full
tuition payment each month whether my child/children is/are sick or on
vacation, etc. since the space is reserved for my child.
I understand that the hours of attendance for my child/children will be from
______ to ______. If my child/children is here beyond that time I will be
assigned a late fee in the amount of _________.
There is a late fee of $20.00 for every five minutes if my child/children is/are
here after 6:00pm.
I have read and understand the tuition policy and have agreed to abide by this
policy with no reservation.

Parents/Guardians Signature _____________________________________.

Date signed________________________________.

CHILDS NAME:_________________________________________________________

TO ALL PARENTS:
ALL STUDENTS WILL BE
RELEASED ONLY TO ADULTS LISTED AS
EMERGENCY CONTACTS OR SAFE PICK-UP
PERSONS. ANY CHANGE TO THIS LIST WILL
ONLY BE AUTHORIZED IF SUBMITTED IN
WRITTEN FORM. THIS MAY BE SUBMITTED
BY FAX OR IN PERSON WITH PARENT
SIGNATURE ONLY. VERBAL REQUESTS WILL
NOT BE HONORED.
Thank you for your cooperation.
MSUP Administration

Please sign __________________________