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

| |Cell: |Home: | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

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)

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download