Leaders of Today Peace Academy 2022 Application

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Leaders Of Today Peace Academy
Margaret Fuller Neighborhood House
71 Cherry Street Cambridge, MA 02139 | (617) 547-4680
Contact: Amanda Perez, Program Manager | aperez@margaretfullerhouse.org

Email *

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Vèsyon kreyòl: https://forms.gle/n1Spxodm4CzbhjSK9

Versión en español: https://forms.gle/MUAjes1izayiHfDK8

Additional Documents

-Copy of Parent ID
-Copy of Child's Birth Certificate or Passport
-Proof of Residence (copy of utility bill/lease/notarized letter from landlord)
-Income Verification: 1 month of paystubs AND/OR documentation of all additional financial assistance sources - Child Support, Social Security, Disability, Housing, etc.
-Immunization Records and Record of Most Recent Physical
-Child and Adult Child Care Food Program Forms (these will be emailed after application is submitted)

Certain families MAY need to submit Specific Documents
If a child has a Chronic Health Condition/ Medication Requirement:
-Independent Health Care Form for EACH condition (signed by doctor) - (this will be emailed after application is submitted)
-Medication Consent Form - (this will be emailed after application is submitted)
-All medications child requires (prescribed/over-the-counter) in original packaging - MUST HAVE ON FIRST DAY CHILD ATTENDS

Updated Child Custody Documents (between parents, adoption/foster care/change of guardianship)

If a child has an Independent Education Plan (IEP)/504 plan:
-Copy of most recent, full IEP/504 plan
-Copy of most recent IEP Progress Report

Documentation can be submitted through email at aperez@margaretfullerhouse.org

Today's Date *

YYYY

Child's Information

Child's Name *

Home Address *

Date of Birth *

YYYY

Sex *

Female

Male

Other:

Eye Color *

Hair Color *

Height *

Weight *

School *

Program Enrollment Schedule

LOTPA is offering the following programming to families:
-Summer Program: 8:30AM-5:30 pm
-Afterschool Program: 2PM-6PM
-Full Day Program: 8AM-6PM

Child's projected start date: *

YYYY

Child's projected schedule:

Monday

Tuesday

Wednesday

Thursday

Friday

Summer Program (8:30AM-5:30PM)

After School (2:00PM-6:00PM)

Current Grade *

Teacher(s) *

Child's Physician/Clinic *

Physician/Clinic Phone Number *

Physician/Clinic Address *

Insurance Carrier *

Policy Number *

Child's Dentist *

Dentist's Phone Number *

Special Concerns or Limitations (e.g. dietary restrictions; allergies; health problems; and specific emotional or learning needs.) If none, please write "none." *

Does your child have an IEP (Individual Education Plan) or 504 Plan? *

Yes

In the process of starting one

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