Enrollment Form

Emergency Contact 1
1st Person Authorized to pick up child*

First NameLast Name
Phone Number*

Area CodePhone Number
Emergency Contact 2
2nd Person Authorized to pick up child

First NameLast Name
Phone Number

Area CodePhone Number
Physician and Medical Information
Doctor's full name

First NameLast Name
Phone Number

Area CodePhone Number
Preferred Hospital
Insurance/Health Coverage (Company)
Please list any of the following: Current medications, Medication allergies, Food allergies, Chronic health concerns.

Permissions & Authorizations
Emergency Medical Treatment

In case of emergency, we hereby authorize (by our indication below) the Administrator or Teacher to call our physician or take our child to the hospital to receive appropriate emergency treatment.
Medical permission *

We authorizeWe DO NOT authorize
Field Trip

I hereby authorize my child to participate in field trips and programs with his/her class. I agree not to hold the School (including its board, officers, staff and volunteers) liable to any and all claims that may arise out of his/her participation in school trips and programs. Note: Parents will receive advance notice about field trips held throughout the year.
Field Trip permission*

We authorizeWe DO NOT authorize
Photograph / Video Release

I hereby give permission to use the photograph/video of the minor named above for publicity, promotion, news release, videos and web use of the school. This might also apply to the written composition or visual art of the minor if it is published. *
Photograph / Video Permission*

We authorizeWe DO NOT authorize
Other Information
Does your child have any learning issues that we should be aware of (ADD, ADHD, speech and language, dyslexia, developmental delays, etc.)?*
Does your child have any medical concerns (allergies, medications, etc.)? Please be specific.*
Is there anything else you think we should know about your child (temperament, strengths, friends, etc.)?*
Should be Empty: