Child Enrollment & Information Form – New Summit Preschool Step 1 of 4 25% Child Enrollment & Information Form - New Summit PreschoolChild InformationChild’s Name Child’s First Name Child’s Middle Name Child’s Last Name Child’s NicknameChild’s Birth date GenderMaleFemaleHome LanguageChild’s Race/EthnicityChild Lives With?Is there a court-ordered custody arrangement for this child?YesNoIf yes, please provide a copy Drop files here or How did you hear about our preschool(s):FriendWord of MouthSignSpecial EventReferral AgencyWebsiteBrochureClass Enrolled in: MWF Schedule - $228/month (AM Class) MWF Schedule - $228/month (PM Class) T/Th Schedule - $152/month (AM Class) T/Th Schedule - $152/month (PM Class) M-F Schedule - $380/month (AM Class) M-F Schedule - $380/month (PM Class) M -F Full Day- $700/month Summer Preschool Program AM classes are from 8:15am-11:15am PM classes are from 12:15pm-3:15pm Full Day class is 8:15am – 3:15pm Family InformationParent #1Parent or Guardian 1 First Last Relationship to ChildEmail Address Home Address Street Address City State / Province / Region ZIP / Postal Code Home PhoneWork PhoneCell PhoneOccupation/EmployerEmployer Address Street Address City State / Province / Region ZIP / Postal Code Parent #2Parent or Guardian 2 First Last Relationship to ChildEmail Address Home Address Same as parent 1 Street Address City State / Province / Region ZIP / Postal Code Home PhoneWork PhoneCell PhoneOccupation/EmployerEmployer Address Street Address City State / Province / Region ZIP / Postal Code Contact InformationLocal contact person (e.g. friend, neighbor or relative) if parent/guardian is unavailable that can be contacted in case of emergency. Please prioritize contacts in order of who should be called first. At least one must be listed as an Emergency contact.Contact #1Contact #1 NameRelation to ChildOK to pick up?YesNoEmergency Contact?YesNoPhoneAddress Street Address City State / Province / Region ZIP / Postal Code Contact #2Contact #2 NameRelation to ChildOK to pick up?YesNoEmergency Contact?YesNoPhoneAddress Street Address City State / Province / Region ZIP / Postal Code Contact #3Contact #3 NameRelation to ChildOK to pick up?YesNoEmergency Contact?YesNoPhoneAddress Street Address City State / Province / Region ZIP / Postal Code Contact #4Contact #4 NameRelation to ChildOK to pick up?YesNoEmergency Contact?YesNoPhoneAddress Street Address City State / Province / Region ZIP / Postal Code Medical InformationChild’s PhysicianPractice NamePhysician’s PhonePhysician’s Address Street Address City State / Province / Region ZIP / Postal Code Child’s DentistPractice NameDentist's PhoneDentist’s Address Street Address City State / Province / Region ZIP / Postal Code HospitalHospital PhoneHospital Address Street Address City State / Province / Region ZIP / Postal Code Check the box beside the statements: I agree to have my child examined by a physician annually and medical information returned to Diakonia for their files. I agree to provide a copy of my child’s current immunization records or sign an exemption form. Specific Health ConcernsAllergies?YesNoif yes, please specifyRestrictions?YesNoif yes, please specifyOperations or Serious Illnesses:YesNoif yes, please specifyAny medication or lifesaving equipment (e.g. EpiPen’s, inhalers etc.) require additional written medical plans provided by our school and signed by guardian, doctor, and the Diakonia staff nurse.List any behavior or exceptional need considerations for your childHealth Insurance?YesNoInsurance CompanyPhone NumberInsurance Address Street Address City State / Province / Region ZIP / Postal Code Policy NumberGroup NumberPlease check the box beside the statements: I as the parent/guardian authorize the Diakonia preschool staff, to have access to my child’s health information as provided to Diakonia (General Health Appraisal form, Immunization records, Health Insurance Coverage Information, specific health care plans). I understand that the records will be reviewed for completeness by office staff and the Diakonia nurse consultant, and may be accessed other times through the school year by Colorado’s State Licensing Representative on an individual or as needed basis. it is our policy to notify a parent when a child is ill or needs medical attention. Occasionally we cannot contact parents and we need to get immediate help for the child. Please sign the consent below so that we can take appropriate action on behalf of your child. We will take this signed consent with us to the emergency center. I authorize the Diakonia Preschool staff to call a physician, or summon an ambulance for emergency medical aid; should, in the opinion of the person(s) in attendance, feel such services are required. If such emergency should arise, I shall be notified as soon as possible. I agree that any cost incurred for such services shall be the sole responsibility of me. Permission FormsI give Diakonia permission to list my name and phone number in our preschool directory and on the class list on Shutterfly©.YesNoI give Diakonia permission to send (individual and group) e-mails and or text messages concerning late starts, weather closures, reminders, newsletter, special events, and other updates.YesNoI give Diakonia permission to follow up on the progress of my child’s school readiness and progress after leaving preschool and entering elementary school. This follow-up may occur as many as two times per year via phone or email in a survey style form. This information may be shared with Diakonia staff, private contributors and grantors. No names will be included in the collection of this data.YesNoI give Diakonia permission to apply sunscreen to my child. Diakonia will provide the sunscreen. If your child has any skin allergies to sunscreen please let the director and your child’s teacher know and provide your individual child with their own sunscreen.YesNoI give permission for my child to be photographed, or their images recorded to be uploaded on Diakonia’s website, Facebook, Shutterfly©, classroom projects, and in marketing materials used to secure grants.YesNoI give permission for my child to participate in Walking Field Trips in the local area near my child’s Diakonia Preschool, accompanied by the classroom teachers.YesNoI give permission to Diakonia to contact me via Facebook© for advertising and marketing of events and services.YesNoI agree to comply with the program rules which are established and periodically amended by board members of Diakonia.YesNoI agree to inform Diakonia of any information changes.YesNoI understand that while constant supervision of my child is provided by the Diakonia staff, there is inherent risk of injury to my child from activities in the classroom, on the playground and in the building facilities. I accept this risk and on behalf of me an d my spouse, if applicable, my child, and his/her and our heirs and legal representative, waive and release Diakonia from any and all claims (excluding only willful misconduct) for injuries sustained by my child while in the Diakonia program, and waive and release any claim for consequential and exemplary damages. I agree to indemnify and hold harmless and its agents and employees from any claim brought by or on behalf of my child, which is inconsistent with the above waiver and release.YesNoSign here as the parent/guardian to acknowledge compliance with the above policies, permissions, medical emergencies, and waivers for:Parent/Guardian’s SignatureToday’s Date Make a PaymentRegistration Fee Price: $75.00 Usage Fee Price: $0.00 Credit CardEnter your credit card information to pay the registration fee American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20202021202220232024202520262027202820292030203120322033203420352036203720382039 Expiration Date Security Code Cardholder Name
