JK - Grade 6 Application | B.E.N. School-House

Thank you for your interest in the B.E.N. School-House. Please complete all sections of this application form. All information provided will be kept strictly confidential.

1 Student Info

2 Family Info

3 Medical & Emergency

4 Health History

5 Agreements

Student Information

Student's First Name *

Student's Last Name *

Gender *

Date of Birth *

Grade Applying For *

Current Grade (if applicable)

Present School (if applicable)

School Address

School Telephone

Important Questions

Does the student have any allergies, sensitivities or medical/health issues that the BEN School should be aware of? *

Yes No

Are there any psychological evaluations or educational plans (IEP)? *

Yes No

Has the student experienced any issues or discipline related to behaviour or self-regulation in school? *

Yes No

Parent/Guardian Information

Parent(s) or Guardian(s) Name(s) *

Primary Address

Street Address *

City *

Province *

Postal Code *

Secondary Address (if applicable)

Street Address

City

Province

Postal Code

Contact Information

Email #1 *

Email #2

Cell #1 *

Cell #2

Personal Information

This information helps us get to know your family. All information is kept strictly confidential.

Siblings (name, gender, and age)

Do you have any pets? If so, please list (include names)

Is there any particular event (positive or negative) that has had a strong impact on your child?

Please give an overview of your child's personality, temperament and character

Please share your views, ideals and practices with regards to parenting and childcare

Medical History & Emergency Contacts

All information provided will remain confidential.

Employment Information

Parent/Guardian Employment

Work Phone #1

Work Phone #2

Medical Information

Child's OHIP #

Doctor's Name and Phone Number

Emergency Contacts

Please provide contacts who can be reached in case of emergency (in addition to parents).

Emergency Contact #1 *

Name *

Phone *

Relationship to Child *

Emergency Contact #2

Name

Phone

Relationship to Child

Emergency Contact #3

Name

Phone

Relationship to Child

Health History of the Child

Child's Blood Type (if known)

Has your child been diagnosed with any medical condition (short term, long term, or permanent)?

Is your child currently taking medication? If so, what kind and how often?

Does your child have any allergies?

Is your child on a specific diet? If so, please explain.

Is your child immunized? *

Yes No Partially

Please provide a photocopy of immunization record or a legal letter of exception. This is a requirement by the Ministry of Health.

Please provide any additional health information you feel would be useful for us to have.

Emergency Protocol: In case of a life-threatening situation, our protocol is to call 911 first, after which the parents or emergency contacts will be called immediately.

Terms of Registration & Permissions

Terms of Enrollment

Please read and acknowledge the following terms:

Post-dated monthly tuition payments for the first of each month are due on June 1st by cheque or money order made out to "Balanced Education Network" or "The B.E.N."
There will be a $40 late fee for tuition payments received after the 1st of each month. NSF cheques incur a $40 fee.
Tuition is calculated on an annual basis with no fee reductions for holidays, illness, vacations, or emergency closings including snow days.
If withdrawing your child before the school year ends, 90 days notice is required. Failure to notify results in responsibility for three months' tuition.
Registration forms are required before the child starts school.
The school reserves the right to dismiss a child whose conduct, influence, physical needs, or condition is deemed disruptive or potentially harmful.
B.E.N. staff are mandated to report any suspected child abuse.

I have read and agree to the Terms of Enrollment *

I grant parental consent for minor medical (first aid) treatment during my child's enrollment. Should I be unavailable during an emergency, I grant permission for staff to secure emergency medical treatment. *

I give permission for my child's photograph and/or artwork to be used in School-House and B.E.N. publications.

I agree to the General Release: to release and hold harmless The B.E.N., its officers, trustees, agents, and employees, from any and all claims in connection with or arising out of the school and child care service, except for loss or injury occasioned by gross negligence or intentional misconduct. *

Pick Up Authorization

In addition to parents/guardians, the following person is authorized to pick up your child:

Name

Phone

Address

Relationship to Child

Leave Premises Permission

Community life is an important part of The School-House program. This permission allows teachers to take your child off the premises to walk about the neighbourhood, go to the library, or to play in local parks (bounded by St. Clair Ave./Oakwood Ave. and Eglinton Ave./Caledonia Rd.).

I give permission for my child to leave the premises of The B.E.N. (394 Harvie Ave.) to explore the neighbourhood and visit local parks. This permission is granted for the duration of the child's enrollment.

Electronic Signature

Parent/Guardian Full Name *

I agree that typing my name above represents my electronic signature and has the same legal effect as a handwritten signature. *

How did you hear about B.E.N. School-House?

* Required fields

JK - Grade 6 Application

Application Package

Student Information

Important Questions

Parent/Guardian Information

Primary Address

Secondary Address (if applicable)

Contact Information

Personal Information

Medical History & Emergency Contacts

Employment Information

Medical Information

Emergency Contacts

Emergency Contact #1 *

Emergency Contact #2

Emergency Contact #3

Health History of the Child

Terms of Registration & Permissions

Terms of Enrollment

Pick Up Authorization

Leave Premises Permission

Electronic Signature