Nursery School Registration Form

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Class Requested

3 Mornings - Monday, Wednesday, Friday

2 Mornings - Tuesday, Thursday

Personal Information

Name of Child *

Date of Birth *

Month

Day

Year

Mother

Name of Mother *

Home Phone *

Work Phone

Mobile Phone

Email *

Primary Address *

Occupation

Other Parent

Other Parent Name

Other Parent Phone

Other Parent Occupation

Are there any custody issues for your child? Please give details *

Emergency Contacts Person

Emergency Contacts Persons Name (other than parents) *

Emergency Phone

Relationship to Child

People authorized to pick up child from school (other than mother or father)

1. Name *

1. Relationship to Child

1. Phone Number

2. Name

2. Relationship to Child

2. Phone Number

3. Name

3. Relationship to Child

3. Phone Number

Does your child have any diagnosed medical, behavioral conditions and/or allergies

Family Doctor

Family Doctor Name *

Family Doctor Phone *

Family Doctor Address *

MSI Number and expiry date on card *

Medical History

Has your child had any of the following *

	Yes	No
Measles *	Measles - Yes	Measles - No
Whooping Cough *	Whooping Cough - Yes	Whooping Cough - No
German Measles *	German Measles - Yes	German Measles - No
Chicken Pocks *	Chicken Pocks - Yes	Chicken Pocks - No

Other

Any history of the following

Any history of the following *

	Yes	No
Skin Conditions *	Skin Conditions - Yes	Skin Conditions - No
Ear Infectons *	Ear Infectons - Yes	Ear Infectons - No
Asthma *	Asthma - Yes	Asthma - No
If yes, does your child have a puffer *	If yes, does your child have a puffer - Yes	If yes, does your child have a puffer - No
Seizures *	Seizures - Yes	Seizures - No
Croup *	Croup - Yes	Croup - No
Bronchitis *	Bronchitis - Yes	Bronchitis - No
Pneumonia *	Pneumonia - Yes	Pneumonia - No

Other

Immunizations (please give dates)

DtaP-IPV-Hib Pneumo Conj (2 months/4 months)

1st Dose-2 months *

2nd Dose-4 months *

3rd Dose-6 months *

MMRV Meningococcal C Pneumo Conj. - 12 months (first dose) *

DTaP-IPV-HiB MMRV* - 18 months (2nd dose between 18 months - 6 years) *

Tdap-IPV MMRV* - 4 to 6 years (2nd dose between 18 months - 6 years) *

Other Immunizations? I.E. Annual Flu Shot

Is your child receiving medications or treatment for any reason? *

Please give details, including names/dose of mediciation

Are there any recommendations for diet? *

Is your child free from communicable diseases? *

	Yes	No
Is your child free from communicable diseases? *	Is your child free from communicable diseases? - Yes	Is your child free from communicable diseases? - No

Please list names / ages of siblings

Does your child have any fears?

Do you have any concerns about your child's development?

Occasionally *

	Yes	No
Occasionally we may take photos at school of our children at parties or other special events. Can your child be included in these photos? *	Occasionally we may take photos at school of our children at parties or other special events. Can your child be included in these photos? - Yes	Occasionally we may take photos at school of our children at parties or other special events. Can your child be included in these photos? - No
In the past we have had a professional photographer come in to do individual and class pictures. Do you want your child's picture taken? *	In the past we have had a professional photographer come in to do individual and class pictures. Do you want your child's picture taken? - Yes	In the past we have had a professional photographer come in to do individual and class pictures. Do you want your child's picture taken? - No
Occasionally we go on field trips to the library and park; we always give parents advance notice of thesr outings. Do you give permission for your child to go on these trips? *	Occasionally we go on field trips to the library and park; we always give parents advance notice of thesr outings. Do you give permission for your child to go on these trips? - Yes	Occasionally we go on field trips to the library and park; we always give parents advance notice of thesr outings. Do you give permission for your child to go on these trips? - No

I understand that my child may attend nursery school from 8:45-11:15 a.m. on the days specified. I will pay my child’s fees on the dates outlined in the Payment Schedule provided by the school, unless special arrangements are made through the Director. I assume all responsibility for transportation of my child to and from the nursery school. I also understand that I must assume responsibility for any expense incurred through the school in dealing with emergency injury to or illness of my child, including ambulance costs. In addition, I give permission for the school to call an ambulance or to contact a doctor of their choice should they be unable to contact me or our family doctor, in case of emergency

I certify that all information provided on this form is, to the best of my knowledge, true *

I certify that all information provided on this form is, to the best of my knowledge, true

I Agree

Signature

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Date of this signature *

Month

Day

Year

Parent Committee

I have recieved a copy of the Parents Handbook *

Yes

I am interested in being part of the Parent Committee which meets 2x/year during school hours. *

Yes

* A non-refundable fee of $20.00 ($30.00/family) is due upon enrollment.