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PreschoolStudentEnrollmentForm

ChildsName:_______________________________________Date:______________________

Childsage:_______________________________

ChildsBirthday:________________________Nickname:____________________

Address:_______________________________________________________________________

_____________________________________________________________________________

Parent/GuardianContactInfo:

Momsname:________________________________________________

Dadsname:_________________________________________________

Guardianname:______________________________________________

(Mother)HomePhone:____________________________________

(Mother)WorkPhone:____________________________________

(Mothers)CellPhone:____________________________________

(Father)HomePhone:_____________________________________

(Father)WorkPhone:_____________________________________

(Fathers)CellPhone:_____________________________________

EmergencyContactInformation

EmergencyContactPerson#1:_____________________________

Relationshiptochild:_____________________________________

Contactsphone:_________________________________________

EmergencyContactPerson#2:______________________________

Relationshiptochild:______________________________________

Contactsphone:__________________________________________

Doyouhaveabackupcareprovider(circleone)?YesorNo

Ifyes,pleasegivenameandcontactnumber:
_______________________________________________________________

Scheduling

Beginningdateofenrollment:_____________________________

Pleaseselectprogram:
FulltimePreschoolProgram(MondaythroughFriday8:30am5:30pm)
IncludesFreshOrganicLunch,andhealthysnacksinthemorningandafternoon
ModifiedPreschoolProgram(pleasespecifydropoffandpickuptimesbelow,andnote,
thereareadditionalfeesforearlyandlatepickups)

ModifiedProgramHours:
Monday____________________
Tuesday____________________
Wednesday______________________
Thursday________________________
Friday______________________

Timeyouplantodropoffyourchild________
Timeyouplantopickupyourchild_________

PaymentInformation
PaymentSchedule(selectone):
Weekly,eachFriday=$330/week
Monthly,onthelastdayofthemonth=$1,200/month(discount10%off)
Biannually(inSeptemberandFebruary)=$6,500everysixmonths(18%off)
Paymentmethod
Personalcheck
Paypal
Cash

YourChildsHealth

CHILD'SHEALTHRECORD:(Acopyofacurrentphysicalwillbeneeded)

Generalstateofhealth:
________________________________________________________________________

________________________________________________________________________

Doctorsname_____________________________________________________

Doctorsphonenumber_______________________________________________

Dentistsname_____________________________________________________

Dentistsnumber___________________________________________________

Areyourchild'simmunizationsuptodate?_________(Asstatedinourhandbook,werespecta
parentsrighttochoosewhethertheyvaccinatetheirchild,weaskforthisinformationonlyasa
matterofrecord)

Doesyourchildhaveanyknownallergies(includingfoodallergies)?
__________________________________________________________________________

Areyouconcernedthatyourchildmaybepronetoanytypeofallergies?___________
Describe:
______________________________________________________________________________

Arethereanydietaryrestrictionsorfoodsyourchildshouldavoid?Pleaseexplain.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Doesyourchildhaveanymedicalconditionswhichweshouldbemadeawareof?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Hasyourchildhadthefollowingchildhoodillnesses?(pleaseselect)
Doesyourchildhadtroublewithanyofthe
following?

Constipation
Convulsions
Diarrhea
FaintingSpells
FrequentColds
FrequentEarInfections
FrequentSoreThroats
Lice
Ringworm
SkinRash
Soiling
StomachUpsets
UrinaryProblem
Soiling/wettingthebed
Phobias
Anxiety

Hasyourchildhadanyofthesechildhood
diseases?

Asthma
Bronchitis
Chickenpox
Mumps
Measles
Polio
ScarletFever
Tuberculosis
WhoopingCough
Hepatitis
Diabetes
Obesity
GermanMeasles

Doesyourchildhaveanyspeech,hearingorvisualproblems?

__________________________________________________________________________

Wouldtherebeanyrestrictionstoplayoractivities?Pleaseexplain.
__________________________________________________________________________

AboutYourChild

Hasyourchildeverbeeninchildcare/Preschoolawayfromhomebefore?_________

Whattype(center,familydaycare,grandmaetc.)?_________________________________

Wasitapositiveexperience?___________________________________________________

WhatisthemostimportantthingyouarelookingforinaPreschool?
___________________________________________________________________________

Howdoesyourchildfeelaboutdaycareandbeingleftbyhis/hermommy/daddy?

___________________________________________________________________________

Arethereanyrecenttraumatic/lifechangingsituationsthechildhasbeenexposedtosuchasa
deathinthefamily,divorce,newsiblingetc.?
_____________________________________________________________________________

Whatisyournormalmethodofdiscipline?
_____________________________________________________________________________

Whatisyourchild'stemperament?Ishe/sheeasygoing,calm,bright,demanding,aggressive,
playful,silly,energetic,cooperative,introverted,extrovertedetc.?
______________________________________________________________________________

______________________________________________________________________________

Whatis(are)yourchild'sfavoritefood(s)?
______________________________________________________________________________

______________________________________________________________________________

Whatfood(s)doesyourchilddislike?_______________________________________________

______________________________________________________________________________

Doyouencouragetryingnewfoodsathome?YesorNo

Isyourchildpottytrained?YesorNo

Howdoesyourchildindicatehis/herneedtousethebathroom?

______________________________________________________________________________

Whatwordsdoesyourchildusefor:Bowelmovements__________urination___________

Whattimedoesyourchildwakeup?___________________________________________

Whattimedoesyourchildgotosleepatnight?__________________________________

Dotheysleepthroughthenight?______________________________________________

Doesyourchildsleepinabedorcrib,other?____________________________________

Arethereanysiblings?Pleasenamethemandspecifyagesandgender.
Name_____________________age__________________gender_______________
Name______________________age__________________gender_______________
Name______________________age__________________gender_______________

Hasyourchildhadexperienceplayingwithotherchildren?__________________________

__________________________________________________________________________

Whatlanguagesarespokenathome?
________________________________________________________________________

Doesyourchildhaveanysecurityobjectssuchasablanket,soother,bottle,toyetc.?
_________________________________________________________________________

Whatareyourchild'sfavoriteactivities,toys,books,orgames?
_________________________________________________________________________

Arethereanyotherinformation/concernsaboutyourchildyouwouldlikeustoknowabout?

_________________________________________________________________________