Welcome to the Noah's Ark Learning Center 2023-2024 School Year Application

Thank you so much for your interest in applying for the Noah's Ark Learning Center. In this application you will be filling out the following information: Your child's information, caregiver information, emergency contact information, medical information, consents, acknowledgements, pertinent medical and developmental information. Please gather all this information together before filling out this form, as it will make the application process easier on you.

If you have any questions, please feel free to contact our office at noahsark@fbcbentonville.org

When you are ready to begin the application, please click the "Begin Application" button below.

Child's Information

Child's Name

First

Middle

Last

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Birthdate

Gender

Caregiver Information

Primary Caregiver

Name

First

Last

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Relationship to child

Address

Address Line 1

Address Line 2

City

State

Zip Code

Email

Confirm Email

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Home Phone

Work Phone

Cell Phone

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Place of employment

Work hours (from)

Work hours (to)

Is there a secondary caregiver?

Secondary Caregiver

Name

First

Last

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Relationship to child

Address is the same as primary caregiver

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Home Phone

Work Phone

Cell Phone

Email

Confirm Email

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Place of employment

Work hours (from)

Work hours (to)

Emergency Contact Person

Name of person to call if parents cannot be reached

First

Last

Address

Address Line 1

City

State

Zip Code

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Home Phone

Work Phone

Cell Phone

Authorized Person/People

List all other adults who are authorized to take the child from Noah’s Ark.

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Name

Relationship to child

Phone Number

Medical Information

Rest assured, your privacy is of utmost importance to us. Your medical information will be kept strictly confidential and will only be accessible to authorized personnel of Noah's Ark.

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Child’s Physician or Emergency Treatment Facility

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Checkboxes

I have read and consent to the following

I do hereby give my consent to the Director of Noah’s Ark Learning Center, or her duly representative, for said child to receive medical or surgical aid as may be deemed necessary and expedient by a duly licensed or recognized physician or surgeon in case of an emergency when the parents cannot be reached. Consent is also given for the Director or her duly appointed representative to transport said child for emergency medical treatment, if the parents cannot be reached.

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Name

By putting your name in this field you are electronically acknowledging the above consent.

Date

Consents

Checkboxes

I give consent
I do not give consent

I hereby give/do not give the Director or Noah’s Ark appointed representative permission to give my child Acetaminophen. I understand I will be notified that the medication has been administered.

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I give consent
I do not give consent

I hereby give/do not give written permission for the use of suntan lotions/sunscreen my child in permit-able weather. In accordance with Minimum Licensing Requirements.

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I give consent
I do not give consent

I hereby give/do not give Noah’s Ark Learning Center permission to take photographs or video tape of my child for use in the facility.

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I give consent
I do not give consent

I hereby give/do not give Noah’s Ark Learning Center permission to place photos and/or video recordings of my child on social media or the Noah’s Ark Learning Center webpage.

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Name

By putting your name in this field you are electronically acknowledging the above consents.

Date

Acknowledgements

Checkboxes

I acknowledge that I have read and agree with the following

This is a statement of verification that I have been informed that childcare licensing/child maltreatment investigators and/or law enforcement may possibly interview my child for the purpose of determining licensing compliance or for investigative purposes.

Checkboxes

I acknowledge that I have read and agree with the following

This is to acknowledge that I have received a copy of or given the website address to the electronic version of a list of Kindergarten Readiness Skills for my child (3,4, and 5 Year olds). Calendar: https://humanservices.arkansas.gov/wp-content/uploads/Getting_Ready_for_Kindergarten_Calendar._Print_Version_-1.pdf Checklist: https://humanservices.arkansas.gov/wp-content/uploads/KRIC-PARENT-1.pdf

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I acknowledge that I have read and agree with the following

This is a statement of verification that I have been informed of the behavior guidance policy practiced.

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I acknowledge that I have read and agree with the following

This is a statement of verification that I have received information regarding Shaken Baby Syndrome in accordance with Carter’s Law (all parents of infants).

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Name

This will serve as your electronic signature

Date

Pertinent Medical and Developmental Information

I have provided a copy of my child’s Immunization Record

Yes
No

Disease history

Please indicate if your child has/has not been immunized for the following. If yes, then please enter the date of immunization.

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Measles

Chicken Pox

Mumps

Whooping Cough

German Measles

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Frequent colds

Defective heart

Sun Sensitivity

Fainting spells

Biting

Seizures

Diabetes

Frequent throat infections

Temper tantrums

Contracted Tuberculosis

Frequent ear infections

Please list any and all allergies

Please list any and all medications

Physical or emotional concerns child might have

Other conditions or comments

Special food needs

Formula

Please list formula needs in this area. If no formula needs are required, please enter N/A.

Diabetic diet

Please list diabetic needs in this area. If no diabetic diet needs are required, please enter N/A.

Other food needs

Please list any other food needs in this area. If no additional food needs are required, please enter N/A.

Additional Information

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Is child toilet-trained

Yes
No

Siblings?

Yes
No

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Checkboxes

I understand/agree

I, the parent/guardian of this child, understand that I may ask for a conference with the teacher/caregiver(s) as needed.

Checkboxes

I understand/agree

I have received a copy of the handbook and agree to the policies therein.

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Name

This will serve as your electronic signature

Date