First Step School Enrollment Forms
First Step School Enrollment Forms
(Entire packet must be completely filled out and turned in before your child may start)
General Information Form
Date Entered________________
Child’s Name______________________________________Nickname_____________________________________
Date of Birth__________________________ Present Age_____________________ Sex: male or female
Home Address_______________________________ Home Phone Number__________________
_______________________________ Mom’s Cell #_____________ Dad’s Cell #_____________
Child’s Physician_________________________________ Phone Number _________________________
Email Address: _________________________________ _______________________________________
Parent Signature:____________________________ This signature verifies that First Step has my permission to use this e-mail address to contact me with information about my child, the school and its events, and for the PTO.
Family Background
Father’s Name__________________________________ Birthdate__________________ TDL#_________________
Occupation_________________________________ Education______________________________
Business Name/Address___________________________________________________________________
Business Telephone______________________________ Contact ______________________
Checking account number _____________________________ Bank ____________________ Phone #____________
Mother’s Name__________________________________ Birthdate_________________ TDL#__________________
Occupation_________________________________ Education______________________________
Business Name/Address___________________________________________________________________
Business Telephone______________________________ Contact ______________________
Checking account number _____________________________ Bank ____________________ Phone #____________
Father living? ______ Mother living______ Married _________ Seperated_____________ Divorced___________
Which parent does the child live with? Both____ Mother_____ Father______
Members of household other than parents: (Children, relatives, etc)
Name Date of Birth Relationship to child
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Has the child ever been in a childcare setting? _______ Explain____________________________________________
_______________________________________________________________________________________________
Developmental History
Birth Length____________ Birth Weight _____________ Full term/premature_____________
Can the child: Feed self____ Dress self_____ Brush teeth_____ Bathe self_____ Wipe self_______
Is the child completely toilet trained? (wearing cotton underwear) _________________________________________
Method used to train?_____________________________________________________________________________
Health
Are there any problems connected with the child’s health: eg. Does the child catch colds easily? Is the child’s skin sensitive? Does the child have intestinal upsets often? Any allergies? Other? ________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
Has the child ever had a difficulty with hearing, vision or other parts of the body?_____________________________
Was special help sought?__________________________________________________________________________
Severe injuries Date Operations Date
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
Sleeping Behavior
How long does the child sleep at night?________________What is your child’s bedtime?________________________ Does the child take a nap at home?___________________How long is your child’s nap?________________________
Describe his/her going-to-sleep activities_______________________________________________________________
Summary
Briefly describe what you consider to be the most attractive characteristics of your child?_______________________________________________________________________________________________________________________
What particular ways can we help your child this year?__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Other information that will be important to your child’s teacher or First Step School: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
___I ___________________DO give First Step School Inc. Permission to publish school related photos of my child on the website. I understand I have the right to ask First Step to remove them at any time.
__I _____________ DO NOT give First Step School Inc. Permission to publish school related photos of my child on the First Step School Website.
_____________________________ _______________________
Parent/Guardian Signature Date
___I ____________________DO give First Step School Inc. Permission to publish school related photos of my child on their Facebook account page (for advertising purposes). I understand I have the right to ask First Step to remove them at any time.
__I _____________ DO NOT give First Step School Inc. Permission to publish school related photos of my child on their First Step School Facebook page (for advertising purposes).
_____________________________ _______________________
Parent/Guardian Signature Date
Transportation:
I hereby give my consent for First Step School to provide transportation for my child___________________, on excursion or other planned field trips away from the facility conducted and supervised by facility staff, or in an emergency situation. ________________________________________
Signature of parent
Water Activities:
I hereby give my consent for my child_____________________, to participate in water activities provided and supervised by First Step School. This includes ice play, small tub play. (No swimming pools!)
________________________________________
Signature of parent
Authorization to Reproduce Physical Likeness:
I hereby acknowledge that I expressly grant to the First Step School and to its employee, the right to photograph my child _____________________________, and use his/her picture, voice and other reproductions of physical likeness as the same may appear in any television program, videotape recording, motion picture film, or still photograph for school use only such as art projects, performances, community events, classroom decorations/jacket hooks, cubbies, graduation slideshow, school pictures 2x a year, yearbook, etc.
________________________________________
Signature of parent
I hereby certify and represent that I have read the forgoing and fully understand the meaning and effect thereof, and intending to be legally bound for as long as my child’s is enrolled in the Center, I here unto set my hand this _______ day of __________.
Parent’s Signature______________________________________ Date________________
Signature of Parent
As the parent/guardian of the above child, I give permission for the staff at First Step School to apply sunscreen and/or bug spray to my child when he/she is going to play outside. I understand the sunscreen can be applied to my child’s face, tops of ears, nose, bare shoulders and legs. *This note must be signed and turned in immediately if you want your child to continue to wear sunscreen. Thank you.*
__________________________________________________
Parent Signature Date
As the parent/guardian of the above child, I give permission for the staff at First Step School to apply diaper ointment/baby powder that I have supplied for my child when he/she needs it at a diaper changing. *This note must be signed and turned in immediately if you want your child to continue to have diaper ointment/baby powder applied. Thank you.*
__________________________________________________
Parent Signature Date
Permission for Tylenol or Benadryl
I give my permission for authorized personnel to administer to my child the appropriate dosage of the following medications: Tylenol/Motrin or their equivalents for fever, headaches and minor aches and pains and Benadryl or its equivalent for allergic reactions.
Parent’s Signature_______________________________ Date___________________
WITHDRAWALS
I understand that a 30 day notice in writing must be given to the office if a child is withdrawn. Otherwise, I understand that on month’s tuition will be charged and due regardless of the child’s attendance. The allotted yearly vacation time is given on a yearly basis and may not be used in the 30 day notice or last month’s tuition fee.
___________________________
Signature of parent
HOLD HARMLESS AGREEMENT
Understanding that accident are sometimes unavoidable and/or uncontrollable and understanding that accidents which occur are not necessarily due to negligence of First Step School administration or staff responsible in these situations. The First Step School will be diligent and do everything in its power to control and prevent accidents from occurring.
____________________________
Signature of parent
I have read and agree to abide by First Step school policies. ____________________________
Signature of parent
Authorization for Emergency Medical Care
In order to meet all legal requirements, I do hereby authorize First Step School Employee’s to give consent for any and all necessary emergency medical care for my child or children __________________________________________.
Name of child
___________________________________________
Signature of parent or legal guardian
Physician:
Name_________________________________ Phone Number___________________________________
Address____________________________________
_____________________________________
Emergency Phone Numbers
Home___________________________
Work___________________________ Work______________________________
Cell____________________________ Cell_______________________________
(Mother) (Father)
Other:_________________________________________________________________________
(Pager,etc…)
Emergency Contact other than Mother and Father
Name _______________________________ Numbers____________________________
Address__________________________________________________________________
Relationship to Child________________________________________________________
Immunization Records Release
The following signature grants permission for the release of my child’s immunization/medical records from his or her previous school/doctor’s office.
Parent’s Signature_______________________________ Date__________________
A STATEMENT OF MY CHILD’S SPECIAL NEEDS OR PROBLEMS:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
This includes ALLERGIES, existing illness, previous illness and/or injuries, hospitalization during past 12 months and any medication prescribed for long-term continuous use.
Parent’s Signature ____________________________________ Date______________________
Pick Up list
Please indicated the full names and phone numbers of all persons, including Mother and Father, able to pick up your child. We WILL NOT UNDER ANY CIRCUMSTANCE release a child to anyone not on the list unless we receive a phone call from the parent and a dated fax stating the information. Each person on the wait list will need a valid drivers license and will also be photographed in the office to keep on file. Please note that Minimum Standards states that anyone picking up, must be at least 18 years of age.
Person’s Name (1 per line) Phone Numbers: Cell and Home Relationship
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Financial Agreement Contract
I agree to the following fees $ ___________ for monthly tuition and a $____ annual fee
Method of Payment: All on the first of the month or ½ on the First and ½ on the 15th
(please circle a method of payment)
__________________________ Signature of parent
I agree to the financial agreement contract and the above terms until further notice. I understand that enrollment may be terminated if tuition and late fees are not paid within 5 days of the due date.
It is understood and agree that I shall and will be responsible for any and all collections or legal fees as a result of monies owed by me and unpaid First Step School. _____________________________
Signature of Parent
( This form MUST be filled out by your child’s DOCTOR and returned to First Step by the enrollment date. A copy of your child’s shot records IS NOT ACCEPTABLE. The immunization BRAND must be included. After this form is filled out for the first time, then a copy of the shot records must be obtained and submitted to the office with each immunization until your annual updated paperwork)
FIRST STEP SCHOOL
IMMUNIZATION SCHEDULE AND CHRONIC CONDITIONS FORMS
Child’s Name_______________________ Date of Birth________________ Phone Number ______________
Home Address____________________________ _______________________________
Immunizations: (LIST DATES & BRAND)
Hep B 1. __________ DTP 1.__________ HIB 1._____________ (Brand?__________) IPV 1.__________
2.__________ 2._________ 2._____________ 2.__________
3.__________ 3._________ 3._____________ 3.__________
4.__________ 4._____________
Varicella 1. __________ MMR 1. ___________ PCV7 1.___________ HEP A 1.____________
2.___________ 2.___________ 2.___________ 2.____________ 3.___________
4.___________
Hearing Results: right ear__________ left ear ___________
Vision Results: right eye__________ left eye ___________
Specify approximate date for any of the above not recommended for this child at this time______________________
CHRONIC CONDITIONS:
Special care: For special care conditions as allergy, special diet, restriction on physical activity, specified medications and vitamins, please note condition. (please circle)
• IS this child able to physically and mentally, to participate in group activities? YES OR NO
• IS the child able, to physically and mentally, to participate in physical education classes (age appropriate) YES OR NO
If not, explain_________________________________________________________________________________
• Is this child free of infection and contagious disease? YES OR NO
Doctor’s Signature___________________________________ Date_________________________
(Can fax directly to center at 512-805-7050)
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