Student's Name *

First Name

Last Name

Parent/Guardian's Name

First Name

Last Name

Child's birth date *

MM

DD

YYYY

Has the student attended school previously? *

No

Yes (Please indicate where below)

Emergency Contact #1 *

Parents may NOT be the emergency contact; they will always be called first. One emergency contact MUST be a local contact and be able to pick up the student if parents cannot be reached.

First Name

Last Name

Phone *

(###)

###

####

Emergency Contact #2 *

Parents may NOT be the emergency contact; they will always be called first. One emergency contact MUST be a local contact and be able to pick up the student if parents cannot be reached.

First Name

Last Name

Phone *

(###)

###

####

Physician's Name *

First Name

Last Name

Physician's Phone *

(###)

###

####

Is your child under a physician's care or taking medication on a continuing basis? *

No

Yes (Please explain below)

Does your child have allergies? *

No

Yes (Please explain below)

The parent/guardian agrees to have the child picked up as soon as possible if so requested by the school due to illness. *

No

Yes

The parent/guardian authorizes the school to obtain immediate medical care if any emergency occurs when they cannot be located immediately. *

No

Yes

The parent/guardian agrees to notify the school within 24 hours or the next business day after their child, or any member of the immediate household, has developed a reportable communicable disease, as defined by the State Board of Health, except for life threatening diseases which must be reported immediately. *

No

Yes

The parent/guardian gives authorization for the student to participate in off site walking field trips. *

No

Yes

The parent/guardian gives Great Beginnings Preschool authorization to photograph the student and use the photo and/or other digital reproduction of him/her. *

No

Yes

The parent/guardian gives authorization for the Family's name, mailing address, email address and phone number to be published in the preschool directory which will only be distributed to parents/guardians of students enrolled in Great Beginnings Preschool. *

No

Yes