Enrollment Papers as of May 2014

School will have additional information and paperwork at time of tour

ENROLLMENT FORMS

FIRST PARENT/ GUARDIAN INFORMATION


Last Name First Name




Address City State Zip


Home Phone

Cell Phone

Driver License State Social Security Number



Place of Employment Corp. Partner
Work Address City State Zip
Work Phone Work Hours Title Email Address




How did you hear about us?


SECOND PARENT/ GUARDIAN INFORMATION

Last Name First Name
Address City State Zip
Home Phone Cell Phone
Driver License State Social Security Number
Place of Employment Corp. Partner
Work Address

City State Zip
Work Phone Work Hours Title Email Address
How did you hear about us?


PEDIATRIC PHYSICIAN & DENTIST INFORMATION



Dr. Last Name First Name


Office Phone Number


Address City State Zip


Dentist Name Phone Number


Hospital Name Phone Number


Insurance Carrier Policy #


Primary Insured Social Security Number

CHILD'S BASIC INFORMATION


Last Name First Name Date of Birth

Gender Social Security Number
Restrictions:
Parent * Yes No Comment:
*Where restriction is requested, you must provide documentation showing legal rights.






Please give details of other restrictions

Allergies* Yes No Comment:
*Must have documentation of allergies

CHILD'S PROGRAM INFORMATION


Application Date Expected Start Date
(School Age Child) Name of School Time of Dismissal
Expected Schedule:
Mon Tues Wed Thurs Fri

Program Classroom Tuition Mode Amount
Registration F ee Security Depo sit Start Date Drop Date
Field Trip Yes No Comment:
Photo Yes No Comment:
Other Yes No Comment:



A copy of THIS FORM, for each child, shall be placed in a 1" binder separated alphabetically by
last name and taken on the bus/van for each field trip orto the emergency evacuation site.

AUTHORIZATION FOR MEDICAL TREATMENT OF A MINOR

In the event of an emergency requiring a physician's care, doyou wish us tocall your family physician? Yes

No
Name Phone Number
Address City State Zip
I (we), do hereby state that I am (we are) parent(s) or
legal guardian(s) of _, who resides with me (us) at


I (we), authorize for emergency purposes only, adesignated
employee of the center to transport the above minor by ambulance & consent to any necessary
exam, anesthetic, medical advice and/or medical treatment from aphysician or surgeon licensed to
practice medicine in the State of
Allergies to drugs or food
Last Tetanus/ Diphtheria Booster

Please list any special medications or pertinent information




AUTHORIZATION


Parent(s) Legal Guardian (s) Signature(s) Date


Center Director (witness) Date

EMERGENCY CONTACTS AND AUTHORIZED PICK UP (in order of preference)

Name Relationship Daytime Phone
Name Relationship Daytime Phone
Name Relationship Daytime Phone
Name Relationship Daytime Phone
Name Relationship Daytime Phone

PASSWORD FOR UNUSUALPICKUP AUTHORIZATION


This password should be kept confidential. Only the parent and the Center Director will know it.
The password is used as a mean of positively identifying a parent if they call the center to
authorize an unusual pickup. The pickup person does not need to know the password. They just
need a photo ID.