ARK PRESCHOOL/KINDERGARTEN

   A Ministry of Victory Baptist Church

ENROLLMENT INFORMATION

===========================================================================      Child's Name                                          Date of Birth                    Child's Home Phone Number

____________________________________________________________________________________      Child's Address

____________________________________________________________________________________         Date of Admission                      Date Dropped                    Hours and Days child will be in care

____________________________________________________________________________________       Parent or Guardian Name                                            Address if different from child's address

____________________________________________________________________________________           List telephone numbers where parents may     Mother's telephone      Father's telephone     Guardian telephone               be reached while child will be in care.

____________________________________________________________________________________       Name of person to call in case of emergency if parent/guardian cannot be reached.   Telephone  Relationship

____________________________________________________________________________________               I hereby authorize my child to leave the facility ONLY with the following persons:

____________________________________________________________________________________           List any special problems that your child may have, such as allergies, existing illness, previous serious illness, injuries during the past 12 months, any medication prescribed for long-term continuous use, and any other information which the staff should be aware of:

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

AUTHORIZATION FOR EMERGENCY MEDICAL CARE ===========================================================================             In the event that I cannot be reached to make arrangements for emergency medical attention, I authorize the facility director or person in charge to take my child to:

____________________________________________________________________________________       Name of Licensed Physician                        Address                        Telephone Number

____________________________________________________________________________________            Or to (Name of hospital or clinic):                Address                         Telephone Number

____________________________________________________________________________________               I give consent for necessary emergency medical treatment when my child is in the care of this physician and/ or hospital/clinic.                        

                                                _______________________________________________                                                                             Signature of Parent or Legal Guardian                            Date

____________________________________________________________________________________      Dentist Name:                                                Address                             Telephone Number

____________________________________________________________________________________ TRANSPORTATION:  I hereby ______   give  ______  do not give my consent for my child to be transported and supervised by the facility's staff.

____________________________________________________________________________________            On field trips  ________            To and from home  _______            To and from school _______

____________________________________________________________________________________    WATER ACTIVITIES:  I hereby  ______   give  _____  do not give my consent for my child to participate in water activities.

Splashing pools  _____   Wading Pools  _____  Swimming Pools  _____  Other bodies of water provided by the facility  _________.

____________________________________________________________________________________     Parent's Comments:_____________________________________________________________________

____________________________________________________________________________________ SCHOOL AGE CHILDREN:  My child attends:

Name of School                                                            School's phone number ____________________________________________________________________________________

____________________________________________________________________________________           My child's immunization record is on file at the school and all immunizations and TB tests are current.

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                                                _____________________________________________                                                                                                                                                                                                                                                                           Signature of Parent or Legal Guardian                        Date