Please complete the following Registration Form for your 4-year-old student. Student's Name * First Name Last Name Parent/Guardian's Name First Name Last Name Child's birth date * MM DD YYYY Siblings? Names and ages if applicable * If none please type NA Other household members? Names and their relationship if applicable * If none please type NA Pets (name and type)? * If none please type NA Has the student attended school previously? * No Yes (Please indicate where below) Previous school 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 * (###) ### #### Relationship * 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 * (###) ### #### Relationship * 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) Additional information regarding care/medication Does your child have allergies? * No Yes (Please explain below) Allergy information Other medical conditions or special needs? 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 Electronic Signature * This form is signed electronically by entering your legal first and last name and submitting the form. Thank you!
