School Registration

Child's Application for Enrollment
Date Application Completed:
Date of Enrollment:
Student Information
First Name *
Last Name *
Birth Date *

Month Day Year
Child's Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Doctors Name *

First Name Last Name
Doctors Phone Number *

Area Code Phone Number
Hospital Preference:
I, as the parent/guardian, authorize the center to obtain medical attention for my child in an emergency. Signature of Parent/Guardian

Clear
Father's Address
Full Name *

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
E-mail *
Home *

Area Code Phone Number
Cell

Area Code Phone Number
Work

Area Code Phone Number
Address - Same As Child *

Yes No
Mother's Address
Full Name

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
E-mail
Home

Area Code Phone Number
Cell

Area Code Phone Number
Work

Area Code Phone Number
Number
Address - Same As Child's

Yes No
Does your child have any allergies? *

Yes No
If yes please list, including any food or drug allergies.
Does your child have any medical conditions?
Does your child require any medication? If yes, please list these medications.
Do you authorize us to administer the medications listed above?

Yes No
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. Please list NAME, RELATIONSHIP, ADDRESS & PHONE NUMBER
Contact #2
Contact #3
I, as the operator, do agree, to provide transportation to an appropriate medical resource in the event if an emergency, In an emergency situation other children in the facility will be supervised by a responsible adult. I will not administer any drug or any medication without specific instructions from the physician or the child's parent, guardian, or full-time custodian. SIGN ELECTRONICALLY

Clear
Family religion and/or special preference. Example : Family doesn't celebrate holidays.
Date

Month Day Year
Should be Empty:

Child's Application for Enrollment

Student Information

Father's Address

Mother's Address