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Preschool Admission Form

 

I. Child's Information

 

Basic Information

First Name

Last Name

Preferred Name

Date of Birth

Gender

Home Address

City

State

Zip Code

Place of Birth

Nationality/Citizenship

Child's Photo

Choose a file or drop it here
 

Developmental Information

 

Does your child have any special needs, allergies, or medical conditions we should be aware of?

 

If yes, please describe in details

Has your child received any early intervention services?

 

If yes, please explain.

Does your child have any specific fears or anxieties? (e.g., loud noises, separate anxiety)

If yes, please describe in details

 

What are your child's strengths and interests?

 

What are some areas where your child might need extra support?

 

Language(s) spoken at home

 

II. Parent/Guardian Information

 

Parent/ Guardian 1

First Name

Last Name

Phone Number

Email Address

Occupation

Employer

Relationship to Child

 

Parent/Guardian 2

First Name

Last Name

Phone Number

Email Address

Occupation

Employer

Relationship to Child

Emergency Contact Information (if different from above)

First Name

Last Name

Phone Number

Email Address

Authorized Pick-Up Persons

Please enter.

Name

Relationship

A
B
1
 
 
2
 
 
3
 
 

Not Authorized Pick-Up Persons

Please enter.

Name

Relationship

A
B
1
 
 
2
 
 
3
 
 

III. Program Preferences

 

List the available programs.

 

Please specify your program preferences.

2 days tuition a week

3 days tuition a week

4 days tuition a week

5 days tuition a week

before school care

after school care

before & after school care

Preferred Start Date

 

IV. Medical Information

 

Doctor's Information

 

Child's Physician Name

Phone Number

Clinic/Hospital

 

Insurance Information

 

Insurance Company Name

Policy Number

Immunization Records

Choose a file or drop it here
 

V. Agreements and Permissions

 

Policies and Procedures Acknowledgement

 

I/We acknowledge that I/we have received, read, and understand the [Preschool Name] Parent Handbook, which includes the Preschool's Policies and Procedures. I/We agree to comply with these policies and procedures.

 

Parent/Guardian Signature

Parent/Guardian Signature

Emergency Authorization

 

I authorize the above-named individuals to be contacted in the event of a medical emergency involving me. I understand that this authorization allows healthcare providers to release my protected health information to these individuals for the purpose of facilitating my medical care and well-being. This includes, but is not limited to, information regarding my condition, treatment, and prognosis.


I understand that I have the right to revoke this authorization in writing at any time, except to the extent that action has already been taken based on it.

 

Please sign here

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