VPK Application

Student’s Name:(Required)
Parent/Guardian Name:(Required)
Parent/Guardian Name:
Student’s Address:(Required)
Child’s Date of Birth:(Required)
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Method of Payment:

All payments will be processed through Brightwheel.

Tuition is billed weekly / Payable Monday morning before care is provided.

, hereby acknowledge and agree to the following tuition terms for Gallop’s Family Center, Inc.:

By signing below, I confirm that I have read, understood, and agreed to the tuition terms as outlined above.

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If parents cannot be reached in an emergency situation, the following people should be contacted:(Required)
Phone #
Alternate Phone #


I have received and understand all the childcare policies provided to me in this registration packet. I agree to adhere to all policies and procedures outlined in this packet. I understand I must return these forms before registration is complete.
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will mark the space below to grant or not grant permission of photos of my child to be used in the manner below.
Use still photos in promotional materials(Required)
Display still photos on facility’s website(Required)
Display in facility’s bulletin boards, show to current and prospective clients(Required)


To ensure the safety and security of all children, staff, parents, and visitors, as well as the security of our facility and premises, our center is equipped with a 24-hour video surveillance system. These security cameras are installed in classrooms, indoor and outdoor play areas, and common areas of the facility. Video surveillance is not conducted in private areas of the facility such as restrooms.

Because Gallop’s respects the privacy of all children, parents, and staff in our facility, our 24-hour video surveillance system/security cameras are for internal purposes only. Parents are not allowed to view or have copies of the recording. Recordings are only allowed to be viewed by the Administration, and licensing.
understand the VPK program requires a total of 540 hours during the school term. I commit to bringing my child to class on time and meeting the state requirements of attendance. I understand I will be required to sign a monthly statement certifying my child’s attendance in the program so that payment will be made to Gallop’s Family Center, Inc. from ELC. That statement of attendance is shown below.

I, (Name of Parent), swear (or affirm) that my child, (Name of Student) , attended the Voluntary Prekindergarten Education Program on the days listed above and certify that I continue to choose (Name of Provider or School) to deliver the program for my child and direct that program funds be paid to the provider or school for my child.

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