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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