Enroll Your Child

Enrollment and Authorization Application

Name of Child(Required)

First Middle Last

Nickname

Birthdate(Required)

Desired Start Date(Required)

Parent(s) or Guardian(s) Contact Information

Parent or Guardian Name(Required)

First Last

Relationship(Required)

Home Address(Required)

Street Address Address Line 2 City State ZIP Code

Home Phone

Cell Phone

Email Address(Required)

Employer

Work Phone

Additional Parent or Guardian

Check this box if you would like to add another parent or guardian.

Parent or Guardian Name(Required)

First Last

Relationship(Required)

Home Address(Required)

Street Address Address Line 2 City State ZIP Code

Home Phone

Cell Phone

Email Address(Required)

Employer

Work Phone

Emergency Contacts

We always try to contact parents first. However, we are required to have emergency contacts other than parents. These people are authorized to pick up your child from the facility. Please list all appropriate numbers. Note: It is legal for either parent or caregiver to pick up a child unless we have a copy of a court order restricting visitation.

Emergency Contact Name (1)(Required)

First Last

Relationship(Required)

Home Phone

Cell Phone

Work Phone

Emergency Contact Name (2)

First Last

Relationship

Home Phone

Cell Phone

Work Phone

Emergency Contact Name (3)

First Last

Relationship

Home Phone

Cell Phone

Work Phone

Other Authorized Contacts

List other people authorized to pick up in non-emergency situations. Please include all appropriate numbers. Under no circumstances will students be released to anyone not known to the school without authorization from parents or caregivers.

Authorized Contact Name (1)

First Last

Relationship

Home Phone

Cell Phone

Work Phone

Authorized Contact Name (2)

First Last

Relationship

Home Phone

Cell Phone

Work Phone

Authorized Contact Name (3)

First Last

Relationship

Home Phone

Cell Phone

Work Phone

Arrival Departure Information

Special Arrangements

Describe special arrangements such as school bus, school age children arriving or departing without parents, etc.

Other Schools or Programs

List other schools or programs that your child attends:

Medical Information

It is required by law to have both a doctor and a dentist on record for emergency information.

Physician Name(Required)

First Last

Physician Phone(Required)

Physician Address(Required)

Street Address Address Line 2 City State ZIP Code

Dentist Name(Required)

First Last

Dentist Phone(Required)

Dentist Address(Required)

Street Address Address Line 2 City State ZIP Code

Emergency Hospital Preference(Required)

Medical Restrictions

Please list any medical treatment restrictions.

Known Allergies(Required)

Does your child have any known allergies (food and/or medical)?

Yes

Allergies List(Required)

Please list all allergies below, separated commas (i.e., penicillin, peanuts, etc.).

Other Information

Child's Residential Contact

With whom does the student live with?

Referral Source

How did you hear about our school?

Volunteer Time

Please list any skills or talents that you would like to share with the school as part of your volunteer time:

Terms & Agreement

I hereby grant permission for my child to use all equipment, to participate in all school activities (including swimming under the supervision of a certified life guard) and to leave the school premises under the supervision of a staff member for neighborhood walks or field trips in an authorized vehicle. I further grant permission to photograph my child for publicity or news purposes (on or off site.)

I hereby grant permission for my child to be given age appropriate doses of acetaminophen in order to reduce fever or relieve pain as necessary. I further grant permission for staff to apply sun screen in order to prevent skin damage while playing outside.

I hereby grant permission for the Director or Substitute Director to take whatever steps may be necessary to obtain emergency medical care. These steps may include, but are not limited to, the following:

Attempt to contact a parent or guardian, the child's physician, or the persons listed under emergency contact information.
If we cannot contact you or your child's physician, we will do one or both of the following: (a) Call another physician or paramedics (b) have the the child taken to an emergency hospital in the company of a staff member.
Any expenses incurred under 2, above, will be borne by the child's family.
The school will not be responsible for anything that may happen as a result of false information given at the time of enrollment.
The school will not assume responsibility for a child who has not been signed in upon arrival for the day.

Parent/Guardian Name(Required)

Date(Required)

Signature(Required)

Please sign your name in the box below using a mouse, stylus, or touchscreen.

Additional Parent/Guardian Name

Date

Signature

Please sign your name in the box below using a mouse, stylus, or touchscreen.

Enroll Your Child

Enrollment and Authorization Application

Parent(s) or Guardian(s) Contact Information

Emergency Contacts

Other Authorized Contacts

Arrival Departure Information

Medical Information

Other Information

Terms & Agreement

Preschool Promise

Immunization Reports

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