Nursery School Registration Form

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Class Requested
Personal Information
Other Parent
Emergency Contacts Person
People authorized to pick up child from school (other than mother or father)
Family Doctor
Medical History
Measles *
Whooping Cough *
German Measles *
Chicken Pocks *
Any history of the following
Skin Conditions *
Ear Infectons *
Asthma *
If yes, does your child have a puffer *
Seizures *
Croup *
Bronchitis *
Pneumonia *
Immunizations (please give dates)
DtaP-IPV-Hib Pneumo Conj (2 months/4 months)
Please give details, including names/dose of mediciation
Is your child free from communicable diseases? *
Occasionally we may take photos at school of our children at parties or other special events. Can your child be included in these photos? *
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? *
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? *

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
Parent Committee

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