TIFFANY HUNT



Green Mountain Kids Preschool Program

PO Box 157

Morrisville, VT 05661

Registration Form

Child Information

Child’s Name: ______________________________________________ Date of Birth: __________________

Parent Information

Parent/Guardian Full Name: ____________________________________ Phone: _______________________

Address: ___________________________________________________ Cell phone:____________________

Employer & Work Address: __________________________________________________________________

Email: ____________________________________________________ Work Phone:___________________

Other Parent/Guardian Full Name: ______________________________ Phone: _______________________

Address: ___________________________________________________ Cell phone:____________________

Employer & Work Address: __________________________________________________________________

Email: ____________________________________________________ Work Phone:___________________

Emergency Information

If neither parent can be reached in case of an emergency, call:

Name: _____________________________________________________ Phone:________________________

Address: ___________________________________________________ Relationship: __________________

Name: _____________________________________________________ Phone:________________________

Address: ___________________________________________________ Relationship: __________________

Name of Child’s Doctor: ______________________________________ Phone:________________________

Name of Child’s Dentist: ______________________________________ Phone: _______________________

Hospital Preference: _________________________________________________________________________

Health Insurance Information

Plan Name and Address:______________________________________ Name of Subscriber:_____________

__________________________________________________________ Relationship: __________________

Policy or Certificate No.:______________________________________ ID No.:_______________________

Additional Information about Your Child

Please provide any other information about your child which would be helpful, such as play habits, sleeping habits, fears, likes, dislikes, etc.: _______________________________________________________________

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

How did you hear about Green Mountain Kids? ___________________________________________________

Permission and Understanding Statements

Initial Below:

____ I understand every effort will be made to contact me in case of emergency. I hereby authorize Green Mountain Kids to obtain emergency medical care for my child if I can not be reached.

____ I acknowledge the following has been explained:

• Daily Schedule

• Transportation to/from field trips

• Typical activities (indoor and outdoor)

____ Green Mountain Kids has informed me that they do have liability insurance coverage

____ I have read and signed the Green Mountain Kids Tuition Agreement

____ I have read and understand the Green Mountain Kids Preschool parent handbook

The following persons other than parents are authorized to pick up my child:

1. _____________________________________________ Daytime Phone: ______________________

2. _____________________________________________ Daytime Phone: ______________________

3. _____________________________________________ Daytime Phone: ______________________

4. _____________________________________________ Daytime Phone: ______________________

Signed: ______________________________________ Date: ______________________________

Parent/Guardian

Signed: ______________________________________ Date: ______________________________

Parent/Guardian

Signed: ______________________________________ Date: ______________________________

GMK Director

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