CHA Exchange Program 2019/20 Registration

This is the form for registering your child for our Exchange Program.  Please keep your email confirmation in case you need to edit this form. If you have any questions, please email [email protected] or call 425-372-2800.  

General Information

Parent/Guardian's Signature

Program Fees

I understand that the cost of the Exchange Program is $2,499. I confirm that I will be paying via the following method:

The Exchange Program Registration Fee can be paid by credit card at our store -

Cancellation Policy

If a student needs to withdraw from the Exchange Program, written notice (email acceptable) must be given ?? weeks in advance. I understand that I will be charged the full amount of the program fee if I cancel with less than the required notice.

Parent/Guardian's Signature

Extended Day Policy

Extended Day is available every camp day from 7:00-8:30 a.m. and from 3:30-6:00 p.m. Students must be picked up by 6:00 p.m. or a late pick-up fee of $10/minute will be incurred.

Parent/Guardian's Signature

Parent/Guardian's Information
Emergency Contact 1
Photo and Video Permission

Chestnut Hill Academy takes photographs and videos of children enrolled in its programs on a regular basis for its business purposes. Chestnut Hill Academy retains all rights, title, and interest in these materials and may use and disseminate them in a variety of ways, in its sole judgment. Chestnut Hill Academy takes care that any use, display, or dissemination of photographs or videos of children, whether at a particular school where the child attends or for its general business purposes, is accomplished in a thoughtful, safe, and secure manner appropriate under the particular circumstances.

For example, these materials may be used to better communicate with families and to illustrate the daily curriculum, to chronicle a child’s development, or to document activities. These photos may be shared with you and other families on a secure Chestnut Hill Academy website, on Facebook, by e-mail, posted in the school, or in a parent newsletter.

By signing below, I give permission to Chestnut Hill Academy to take photographs and videos of my child during his/her enrollment and to use these materials for its business purposes. May we use photographs of your child as described?

Parent/Guardian's Signature

Field Trip and Walks Permission

As part of the program, children will go on walks in the surrounding area supervised by the staff, weather permitting. A separate Field Trip Policies and Permission Slip describing the field trip will be sent home if your child will be leaving the school for an extended period of time. I hereby give my permission to Chestnut Hill Academy to remove my child from the premises for neighborhood walks, visits to the playground or park, by means for off-campus field trips requiring transportation.

Parent/Guardian's Signature

Illness, Injuries and Medical Conditions

Child Illness
In case of illness, I will be called and possibly required to pick up my child(ren) as soon as possible. We ask that for your child’s comfort and to reduce the risk of contagion, children be picked up within 1.5 hours of notification. Until then, your child will be kept comfortable and will continue to be observed for symptoms. Children need to remain home for 24 hours without symptoms before returning to the program. This means that the child needs to remain out of the school for the remainder of the day he/she is sent home and the following day (if a child is sent home on Friday, he/she may return on Monday), unless the school receives a note from the child’s medical provider stating that the child is not contagious and may return to the school. In the case of a (suspected) contagious disease, rash, or continuing symptoms, a note from the child’s medical provider may be required before returning.

Children’s Injuries
If my child sustains a minor injury (e.g. scraped knee) during care, I understand that I will receive an Incident Report outlining the incident and course of action taken by the staff member when I arrive to pick up. I will be contacted immediately if the injury produces any type of swelling, is on the face or head, or needs medical attention.

Emergency Medical Care
Every effort will be made to contact me in the event of an emergency requiring medical attention for my child. If I cannot be reached, the emergency contacts listed on the previous page will be called. I authorize Bright Horizons to call an ambulance to transport my child to a hospital or medical facility and to secure for my child the necessary medical treatment. Staff is trained in the basics of first aid and CPR and I authorize them to give my child first aid. In a school, any member of the staff responsible for the care and education of my child may view my child’s health information, as well as state licensors for compliance purposes.

Medical Conditions
If your student has a medical condition or illness (other than asthma or allergies) that requires medication we will need you to submit an 'Individual Health Care Plan' and an 'Administration of Medicine' authorization form. Both forms need to be signed by your primary care provider and are required before your child comes to school, along with the medication which must be in date. If your child has allergies or asthma please complete the Asthma and / or Allergy Care Plan. You can download the forms at the bottom of this page

Parent/Guardian's Signature

Medical Information and Authorization Section
Family Doctor
Family Dentist

If the answer is yes, and your child is not already enrolled in CHA, you must complete an Allergy Healthcare Plan and any relevant Medication Authorization forms which you will find here -

If the answer is yes, and your child is not already enrolled in CHA, you must complete an Asthma Healthcare Plan and any relevant Medication Authorization forms which you will find here

Medical Insurance
Nut Safe Policy

Chestnut Hill Academy is a nut safe zone, as peanuts and tree nuts can cause severe and sometimes life-threatening reactions. In order to maintain a safe environment for all students, nuts and items containing nut ingredients may not be brought onto campus premises. Please check ingredient labels on all food items, as well as lotion and lip balm items, to ensure that the item does not contain nut ingredients or traces of nuts. Only sealed products with ingredient labels verifying there are no nuts, no nut products, and no potential traces of nuts from the equipment used for processing will be served to the children. While coconut is identified by the FDA as a tree nut, few incidences of allergic reactions to coconut are documented, and coconut may be considered the exception to the nut safe rule above. If you pack a lunch for your child which contains nuts, it will be removed, your child will be given a school lunch and you will be contacted.

Parent/Guardian's Signature

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