Gulfton New Student Application - Small Steps Nurturing Center

Student's Name *

First

Last

Date of Birth *

Gender *

Male
Female

Student's Ethnicity *

Hispanic/Latino
Non-Hispanic/Latino

Language(s) Spoken at Home (check all that apply): *

English
Spanish
English and Spanish
Other

I want to add a second student to this application.

Home Address *

Address Line 1

Address Line 2

City

State

Zip Code

The child(ren) lives with: *

Signature *

Clear Signature

Date *

Save and Resume Later

Mother's/ Guardian's Full Name *

First

Last

Mother's/ Guardian's address is same as child(s)? *

Mother's/ Guardian's Cell Phone *

Mother's/ Guardian's Email *

Mother's/ Guardian's Place of Employment

Mother's/ Guardian's Work Phone

Father's/ Guardian's Full Name *

First

Last

Father's/ Guardian's address is same as child(s)? *

Father's/ Guardian's Cell Phone *

Father's/ Guardian's Email *

Father's/ Guardian's Place of Employment

Father's/ Guardian's Work Phone

Signature *

Clear Signature

Date *

Save and Resume Later

Have any other family members attended Small Steps?

Yes
No

Has the student(s) ever attended any other daycare or school (Headstart, HISD, private school)? *

Yes
No

Save and Resume Later

Has the applicant recevied a hearing screening in the past year? *

Yes
No

Has the applicant recevied a vision screening in the past year? *

Yes
No

Please check if your doctor has ever RECOMMENDED any of the following special services: *

Please check if the applicant currently RECEIVES any of the following special services: *

Applicant's Insurance *

Please upload a copy or photo of your child's insurance card. *

Click or drag files to this area to upload. You can upload up to 3 files.

Signature *

Clear Signature

Date *

Save and Resume Later

I/We the parent/guardian of the applicant(s) understand and agree (please read then check all boxes): *

This application will be processed when all required documentation is received.
In place of tuition, I am required to fulfill Parent Tuition Hours yearly. Families with 1 child enrolled are required to complete a minimum of 10 tuition hours each year. Families with 2 or more children enrolled are required to complete a minimum of 15 tuition hours each year. Failure to complete required Tuition Hours will result in inability to re-enroll for the next school year.
If my child is a New Student at Small Steps I am/We are required to complete 4 New Parent Education classes within the first trimester (September through November).
Small Steps Nurturing Center may have mental health professionals, speech pathologists, occupational/physical therapists and/or mental health interns observing, consulting and/or providing direct intervention for physical, social emotional, and developmental concerns in my child’s classroom, and I give my consent to any such intervention. I understand that any direct interventions regarding confidential therapeutic services, requires my written consent, and that it is my/our responsibility to follow-up with any referrals given.
As a condition of enrollment, a signed Parental Consent Request Form, allowing Small Steps to track each child’s progress through school, will be required.
Transportation will be provided only to parents that have no means of getting their child to and from school.

By checking the above boxes you are confirming that you understand and are in agreement with the requirements of applying to Small Steps Nurturing Center.

Signature *

Clear Signature

Date *

Small Steps Income Qualification Form (can be downloaded online) *