2021-2022 OPSF Early Childhood Education Parent Pay Program Registration Form Please enable JavaScript in your browser to complete this form.ECE Available at 6 OPS Elementary Schools Select First, Second and Third Choice. ECE Locations First Choice ECE Location *Select First Choice ECE LocationColumbian ElementaryFullerton ElementaryPicotte ElementarySaddlebrook ElementaryStanding Bear ElementaryWestern Hills ElementarySecond Choice ECE Location *Select Second Choice ECE LocationColumbian ElementaryPicotte ElementarySaddlebrook ElementaryStanding Bear ElementaryWestern Hills ElementaryNo Second Choice - First Choice or WithdrawThird Choice ECE Location *Select Third Choice ECE LocationColumbian ElementaryPicotte ElementarySaddlebrook ElementaryStanding Bear ElementaryWestern Hills ElementaryNo Third Choice - First/Second Choice or WithdrawChild/Student InformationStudent's Legal Name *FirstMiddleLastDate of Birth *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Date of birth must be on or before July 31st, 2017. Gender *FemaleMaleEthnicity *Hispanic/LatinoNot Hispanic/LatinoChoose Not to AnswerRace *AsianBlack or African AmericanNative American or Alaskan NativeNative Hawaiian or Pacific IslanderWhiteChoose Not to AnswerSiblings *Any SiblingsYes, Also Attending OPS SchoolYes, Not School Age YetNo SiblingsSibling Name *Sibling Age *Sibling OPS School Attending *Add Sibling *YesNoSibling2 Name *Sibling2 Age *Sibling2 OPS School Attending *Official Birth Certificate Required - Please select your preferred method to provide documentation *Upload Document File Now*Email Document to OPSF *Fax Document to OPSF*Mail Document to OPSF *If you choose to email, fax or mail document, information and instructions will be emailed once registration is submitted. Upload Birth Certificate Document * Click or drag files to this area to upload. You can upload up to 2 files. Primary Parent/Guardian Information (Primary Account Guarantor) Name *FirstLastAddress *Address Line 1CityNebraskaAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeProof of Residency is Required to Complete RegistrationProof of Residency Required - Please select your preferred method to provide documentation *Upload Document File Now*Email Document to OPSF *Fax Document to OPSF*Mail Document to OPSF *If you choose to email, fax or mail document, information and instructions will be emailed once registration is submitted. Upload Proof of Residency * Click or drag files to this area to upload. You can upload up to 3 files. Relationship to Student *Employer *Email *EmailConfirm EmailEmail will be used for future account access, billing and other communications from OPSF ECE .Cell PhoneHome PhoneWork PhoneWould you like to add a secondary parent/guardian? *YesNoSecondary Parent/Guardian Information (Secondary Account Guarantor) Name *FirstLastAddress *Same as Primary Guardian/Parent AboveEnter Address for Secondary GuardianAddress *Address Line 1CityNebraskaAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeRelationship to Student *Employer *Email *EmailConfirm EmailEmail will be used for future account access, billing and other communications from OPSF ECE .Mobile PhoneHome Phone Work Phone Emergency Contact InformationMinimum of two emergency contacts are required. We will first contact primary and/or secondary guardian(s) before emergency contacts. If authorization for pick up is granted, a photo identification will be required at pick up.Primary Emergency Contact *FirstLastBest Contact Number *Relationship to Student *Pick Up Authorization *Emergency Contact is AUTHORIZED to Pick Up StudentNO PICK UP AUTHORIZATIONSecondary Emergency Contact *FirstLastBest Contact Number *Relationship to Student *Pick Up Authorization *Emergency Contact is AUTHORIZED to Pick Up StudentNO PICK UP AUTHORIZATIONAdd Additional Emergency Contact *YesNo3rd Emergency Contact *FirstLastBest Contact Number *Relationship to Child *Pick Up Authorization *Emergency Contact is AUTHORIZED to Pick Up StudentNO PICK UP AUTHORIZATIONAdd Additional Emergency Contact *YesNo4th Emergency Contact *FirstLastBest Contact Number *Relationship to Child *Pick Up Authorization *Emergency Contact is AUTHORIZED to Pick Up StudentNO PICK UP AUTHORIZATIONChild's Medical HistoryAny LIFE THREATENING Conditions or Allergies *No Life Threatening Conditions or Allergies KnownYES! My Child has a LIFE THREAENING Condition or Allergy - Provide Details BelowALERT !!- LIFE THREATENING CONDITION OR ALLERGY DETAILS *Physician's Name *Physician's Phone *Immunization Records are Required - Please select your preferred method to provide documentation *Upload Document File Now*Email Document to OPSF *Fax Document to OPSF*Mail Document to OPSF *If you choose to email, fax or mail document, information and instructions will be emailed once registration is submitted. Upload Immunization Doucment(s) * Click or drag files to this area to upload. You can upload up to 3 files. Does you child need to take any medication while in school? *NoYes - *OPS Medication Permission Form Required*OPS Medication Policy & Permission Form Required & Available for Download Health Conditions *Allergies - Provide Detail BelowDiabetesAsthmaKidney/Bladder ProblemsEmotional/Mental HealthEating DisorderBirth DefectEpilepsy or Seizures AnemiaNosebleeds (frequent)Bowel ProblemGrowth DisorderCancer/Leukemia Hyperactivity/ADDJoint ProblemsHearing ProblemsRecurrent HeadachesHeart ProblemsScoliosisColor Blindness Skin ProblemsConcussion HistoryOther - Provide Explanation BelowNO Health Conditions or ConcernsPlease Provide Details Relating to Allergies *Please Provide Details of Other Health Conditions or Concerns *Any Special Concerns Not Listed Above? *YesNoPlease Provide Details of Special Concerns *Any Activity Restrictions? *YesNoPlease Provide Details of Activity Restrictions *Consent & PermissionPhotographs, Videos and Broadcast Permission & Consent *Yes, Permission and consent is given to use any photographs, videos, and/or broadcasts of my child.No, Please do NOT use any photographs, videos and/or broadcasts of my child.Signature: I give my permission and consent for the Omaha Public Schools Foundation and/or Omaha Public Schools to include my child in photographs, videos, and/or broadcasts used for the publicity and promotion of the Omaha Public Schools Foundation. *Clear SignatureAcknowledgments & AuthorizationsI understand that my child must be 4 years old on or before July 31st, 2017 to be considered for acceptance to ECE Parent Pay Program. *YesNo exceptions to the ECE age requirement. I understand that my child must be toilet trained, must have age appropriate hygiene skills. *YesI understand there is a $75 non-refundable registration fee to process registration application. *YesRegistration fee is required to complete application process. Non-refundable registration application is processed regardless of acceptance. I understand this program is operated by Omaha Public Schools Foundation as a parent pay program. Weekly tuition is $195 per student. Lack of payment can result in suspension from ECE parent pay program. *YesOnce OPS has 21-22 calendar we provide all accepted families detail fee schedule of annual financial responsibility. I agree to provide all required documents to OPSF ECE and/or OPS to complete registration and acceptance to ECE. *YesBirth Certificate, Current Immunization Records & Proof of Residency. Signature: Primary Parent/Guardian *Clear SignatureSignature: Secondary Parent/Guardian *Clear SignatureSubmit Completed ECE Application to OPSF