Diakonia Preschools

Child Enrollment & Information Form – New Summit Preschool

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Child Enrollment & Information Form - New Summit Preschool
Child Information
Child’s Name
Child’s First Name Child’s Middle Name Child’s Last Name
Child’s Nickname
Child’s Birth date
Gender
- Male
- Female
Home Language
Child’s Race/Ethnicity
Child Lives With?
Is there a court-ordered custody arrangement for this child?
- Yes
- No
If yes, please provide a copy
Drop files here or
How did you hear about our preschool(s):
- Friend
- Word of Mouth
- Sign
- Special Event
- Referral Agency
- Website
- Brochure
Class 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

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Family Information
Parent #1
Parent or Guardian 1
First Last
Relationship to Child
Email Address
Home Address
Street Address City State / Province / Region ZIP / Postal Code
Home Phone
Work Phone
Cell Phone
Occupation/Employer
Employer Address
Street Address City State / Province / Region ZIP / Postal Code
Parent #2
Parent or Guardian 2
First Last
Relationship to Child
Email Address
Home Address
Same as parent 1

Street Address City State / Province / Region ZIP / Postal Code
Home Phone
Work Phone
Cell Phone
Occupation/Employer
Employer Address
Street Address City State / Province / Region ZIP / Postal Code

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Contact Information
Local 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 #1
Contact #1 Name
Relation to Child
OK to pick up?
Yes
No
Emergency Contact?
Yes
No
Phone
Address
Street Address City State / Province / Region ZIP / Postal Code

Contact #2
Contact #2 Name
Relation to Child
OK to pick up?
Yes
No
Emergency Contact?
Yes
No
Phone
Address
Street Address City State / Province / Region ZIP / Postal Code

Contact #3
Contact #3 Name
Relation to Child
OK to pick up?
Yes
No
Emergency Contact?
Yes
No
Phone
Address
Street Address City State / Province / Region ZIP / Postal Code

Contact #4
Contact #4 Name
Relation to Child
OK to pick up?
Yes
No
Emergency Contact?
Yes
No
Phone
Address
Street Address City State / Province / Region ZIP / Postal Code

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Medical Information
Child’s Physician
Practice Name
Physician’s Phone
Physician’s Address
Street Address City State / Province / Region ZIP / Postal Code

Child’s Dentist
Practice Name
Dentist's Phone
Dentist’s Address
Street Address City State / Province / Region ZIP / Postal Code

Hospital
Hospital Phone
Hospital 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 Concerns
Allergies?
Yes
No
if yes, please specify
Restrictions?
Yes
No
if yes, please specify
Operations or Serious Illnesses:
Yes
No
if yes, please specify
Any 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 child
Health Insurance?
Yes
No
Insurance Company
Phone Number
Insurance Address
Street Address City State / Province / Region ZIP / Postal Code

Policy Number
Group Number
Please 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 Forms
I give Diakonia permission to list my name and phone number in our preschool directory and on the class list on Shutterfly©.
Yes
No
I 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.
Yes
No
I 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.
Yes
No
I 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.
Yes
No
I 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.
Yes
No
I 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.
Yes
No
I give permission to Diakonia to contact me via Facebook© for advertising and marketing of events and services.
Yes
No
I agree to comply with the program rules which are established and periodically amended by board members of Diakonia.
Yes
No
I agree to inform Diakonia of any information changes.
Yes
No
I 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.
Yes
No
Sign here as the parent/guardian to acknowledge compliance with the above policies, permissions, medical emergencies, and waivers for:
Parent/Guardian’s Signature
Today’s Date

Online Payment
Yes
No
Make a Payment
Registration Fee
Price: $75.00
Usage Fee
Price: $0.00
Credit Card
Enter your credit card information to pay the registration fee

American Express
Discover
MasterCard
Visa
Card Number Expiration Date Security Code Cardholder Name

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Diakonia Preschools

Step 1 of 4

Child Enrollment & Information Form - New Summit Preschool

Child Information

Family Information

Contact Information

Medical Information

Specific Health Concerns

Any 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.

Permission Forms

Sign here as the parent/guardian to acknowledge compliance with the above policies, permissions, medical emergencies, and waivers for:

Make a Payment

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