STUDENT ENROLLEMENT

Application for Enrollment

Child's First Name

Birthday

Child's Last Name

Child's Nickname

Address

Family Information

Father/Guardian’s Name

Father/Guardian’s Phone Number

Father's Address (if different from child)

Mother/Guardian’s Name

Mother/Guardian’s Phone Number

Mother's Address (if different from child)

Child lives with:

Contacts

Child will be released only to the parents/guardians listed above. The child can also be released to the following individuals, as authorized by the person who signs this application. In the event of an emergency, if the parents/guardians cannot be reached, the facility has permission to contact the following individuals.

Name/ Relationship

Address

Phone

Health Care Needs

For any child with health care needs such as allergies, asthma, or other chronic conditions that require specialized health services, a medical action plan shall be attached to the application. The medical action plan must be completed by the child’s parent or health care professional. Is there a Medical action plan attached?

Yes

(Medical action plan must be updated on an annual basis and when changes to the plan occur)

List any allergies and the symptoms and type of response required for allergic reactions.

List any health care needs or concerns, symptoms of and type of response for these health care needs or concerns

List any particular fears or unique behavior characteristics the child has

List any types of medication taken for health care needs

Share any other information that has a direct bearing on assuring safe medical treatment for your child

Emergency Medical Care Information

Name of health care professional

Office Phone Number

Hospital Preference

Phone Number

I, as the parent/guardian, authorize the center to obtain medical attention for my child in an emergency.

Your Signature

Thank you for applying.