TOWN OF ROCKY HILL
DEPARTMENT OF HUMAN, YOUTH & SENIOR SERVICES
KIDS KORNER APPLICATION
School Year 2018 - 2019
Revised 11/20/2017
GENERAL INFORMATION
The program will follow (with some exceptions) the Rocky Hill Public School calendar for the 2018-19 school
year. It will start after Labor Day in September 2018 and run on Mondays, Tuesdays, Thursdays, and Fridays.
This program will be held at the Rocky Hill Community Center. There will be two sessions each day. One
morning session for 3 year olds that runs from 9:00 to 11:15 a.m. and one afternoon session that runs from
11:30 to 2:30 p.m. This program is for 4 year olds (must be 3 years of age by 9/31/18). Children must be
toilet trained.
CLASS DESCRIPTION
Kids Korner is designed to provide children, ages 3 to 4, with a comprehensive foundation for ongoing learning.
There is an emphasis on social/emotional development, motor development, cognitive and critical thinking.
Student learning will be enhanced through a variety of art and nature based activities.
LOTTERY & REGISTRATION POLICY
Applications will be accepted through January 31, 2018 and may be mailed in or dropped off at the Human
Youth & Senior Services office. Names will be chosen randomly to fill spots. If your child has been selected to
be in the program, you will be contacted by the middle of February, and offered an opportunity to come in and
see the program and meet with the instructors. All applicants that have not been chosen will receive a letter in
the mail by the end of February and be placed on our waiting list.
Applicants that do not initially get into the program will be put on a waiting list for future openings. The wait
list applies to the current year only – a new application must be submitted each year.
Please note that additional paperwork, including a health assessment form which needs to be filled out by your
doctor, must be submitted if your child is accepted into the program. All forms will be held confidential.
FEE STRUCTURE
Upon acceptance into the program, a one-time, non-refundable fee of $100 must be paid by May 1, 2018 to
secure your spot. The total fee for the duration of this program is $2,400. This fee is broken down into 2
payments of $1,200.The first payment of $1,200 is due July 2
nd
. The second payment is due January 1
st
.If
payment is not received by the 15
th
of the month, a $20.00 late fee will be applied. If your payment is not
received by the end of the month, your child will not allowed into the program until full payment is made.
Checks should be made out to the Town of Rocky Hill.
Please return completed form to: Cathy Sylvester
Human, Youth & Senior Services Department
699 Old Main Street
Rocky Hill, CT 06067
Or email completed form to: csylvester@rockyhillct.gov
CHILD INFORMATION
__________________________________________________________________________________________
First Name
Middle Name
Last Name
Date of Birth
Gender (Circle One):
Male
Female
Language(s) other than English regularly spoken at home: ___________________________________________
Does anyone else care for your child on a regular basis? ____________________________________________
If yes, please explain who and how often: __________________________________________________
____________________________________________________________________________________
PARENT / GUARDIAN
__________________________________________________________________________________________
Fathers name Mothers name Last name
__________________________________________________________________________________________
Address
City
State
Zip Code
__________________________________________________________________________________________
Home Phone
Cell Phone
Email Address
BROTHERS AND SISTERS
NAME
GENDER
DATE OF BIRTH
SCHOOL
GRADE
MEDICAL HISTORY
Does your child have any allergies to medications? Circle One:
Yes
No
If yes, please explain medication and reaction: ______________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Does your child have any additional allergies? Circle One:
Yes
No
If yes, please explain: __________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
DEVELOPMENT HISTORY
1.
Can your child be left alone with a baby-sitter without a big fuss?
YES
NO
2.
Does your child have:
a.
Problems with eating?
YES
NO
b.
Problems with sleeping?
YES
NO
3.
Is your child
a.
Highly active?
YES
NO
b.
Very quiet?
YES
NO
c.
Generally a happy child?
YES
NO
d.
Unusually shy?
YES
NO
4.
Does your child:
a.
Cry very easily?
YES
NO
b.
Often have temper tantrums?
YES
NO
c.
Usually follow directions?
YES
NO
d.
Have a very short attention span?
YES
NO
e.
Additional comments: ___________________________________________________________
5.
Is your child
a.
Able to speak most sounds correctly?
YES
NO
b.
Easily understood by other adults?
YES
NO
c.
Hesitant to speak with other adults?
YES
NO
d.
Additional comments: ___________________________________________________________
6.
List your child’s favorite playtime activities: __________________________________________________
_______________________________________________________________________________________
7.
Opportunity to interact with adults other than family:
FREQUENT
OCCASIONAL
INFREQUENT
8.
Able to interact with adults?
YES
NO
9.
Opportunity to play with children outside of family members:
FREQUENT
OCCASIONAL
INFREQUENT
10.
Able to interact with other children?
YES
NO
11.
What words would you use to describe your child? _____________________________________________
_______________________________________________________________________________________
12.
Is there anything further you wish to mention about your child? ___________________________________
_______________________________________________________________________________________
13.
Previous nursery school experience: _________________________________________________________
_______________________________________________________________________________________
Report completed by: _________________________________ Relationship to Child: _________________
Signature: __________________________________________ Date: ______________________________