Online Enrollment Form

Step 1 of 5

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Part 1 - Parent and Child Information

Child First Name(Required)

First

Child Last Name(Required)

Last

Name Called

First

Child Date of Birth(Required)

MM slash DD slash YYYY

Child Gender(Required)

Male

Female

Primary Phone(Required)

Home Phone

Landline only; leave blank if not applicable

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Parent 1(Required)

First Last

Relationship to Child(Required)

Mother

Father

Guardian

Address - If same as child, please skip

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email(Required)

Cell Phone(Required)

Work Phone

Place of Employment

Profession

Parent 2(Required)

First Last

Relationship to Child(Required)

Mother

Father

Guardian

Address - If same as child, please skip

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email(Required)

Cell Phone(Required)

Work Phone

Place of Employment

Profession

Marital Status(Required)

Child Lives With(Required)

Custody/Visiting Arrangements, if applicable

Note: Additional legal documentation will be required if parents are separated or divorced.

If Child Is Adopted (optional)

Age at Adoption

Does child know of adoption?

Yes

Remarks regarding adoption, if applicable

Family Culture (optional)

Ethnicity

Religion

Home Language(s)

Part 2 - Medical Information & Health History

Please check any of the following special issues child may have/have had:(Required)

Allergies

Existing illness

Previous serious illness

Other information of which school staff should be aware

Injuries during the past 12 months

Medication prescribed for long-term use

Hospitalizations during the past 12 months

None

If any of the above are checked, please explain.

Allergies?(Required)

Yes

If yes, type of allergy

Food

Insect Bite/Sting

Seasonal

Medication

Other

Allergic to:

Asthma

Yes

EPI Pen prescribed?

Yes

How does the reaction manifest?

How should the reaction be treated?

Note: An Allergy Action Plan is required for children with diagnosed allergies and a prescribed EPI pen. If no EPI, Allergy Action Plan is helpful. This paperwork will be due no later than one week prior to child’s first day of school.

Dietary Restrictions?(Required)

Yes

If yes, please describe dietary restrictions.

Do you have any concerns about (check all that apply)(Required)

Speech (articulation)

Vision

Language

Hearing

Physical Development

Social Development

None

If so, please explain

Does your child have any diagnosed special needs? (i.e. speech, language, hearing, developmental delay, physical, emotional, behavioral)(Required)

Yes

If yes, please explain

Is your child in any kind of therapy?(Required)

Yes

If yes, type of therapy

Occupational

Speech/Language

Physical

Social Skills/Behavior

If yes, Therapist's Name

Therapist's Phone

If yes, I give permission for the teacher to discuss my child’s therapy with the therapist listed.

Yes

Pediatrician's Name(Required)

Pediatrician's Phone(Required)

Pediatrician's Address(Required)

Street Address Address Line 2 City State ZIP Code

Parent Authorization for Emergency Medical Treatment(Required)

In the event 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 the recommended hospital or to his/her doctor. I give my consent for necessary emergency treatment.

I agree.

Insurance Provider(Required)

Insurance Group / ID(Required)

Part 3 - Authorization to Pick Up

List all persons authorized to pick your child up from school. Both parents must be included.

Name

First Last

Relationship to Child

Phone

I have another person to add.

Name

First Last

Relationship to Child

Phone

I have another person to add.

Name

First Last

Relationship to Child

Phone

I have another person to add.

Name

First Last

Relationship to Child

Phone

I have another person to add.

Name

First Last

Relationship to Child

Phone

I have another person to add.

Name

First Last

Relationship to Child

Phone

I have another person to add.

Name

First Last

Relationship to Child

Phone

I have another person to add.

Name

First Last

Relationship to Child

Phone

I have another person to add.

Name

First Last

Relationship to Child

Phone

I have another person to add.

Name

First Last

Relationship to Child

Phone

I have another person to add.

Name

First Last

Relationship to Child

Phone

I have another person to add.

Name

First Last

Relationship to Child

Phone

Consent(Required)

I authorize only the persons on this list to pick up my child from St. Luke’s Day School. Persons unknown to the Welcome Desk administrator and/or teachers must present a photo ID.

I agree

Part 4 - Introduce Us to Your Child

My child is enrolled in an Infant, Toddler, or Twos class(Required)

Yes

At the time of delivery, was your child(Required)

Were there any complications during pregnancy?(Required)

Age at which child crawled(Required)

Age at which child sat alone(Required)

Age at which child walked(Required)

Age at which child named simple objects(Required)

Does your child use a pacifier?(Required)

Yes

If yes, when?

Are you currently nursing your child?(Required)

Yes

Does your child drink from:(Required)

Bottle

Sippy Cup

Cup

Is there any special information about your child’s eating, sleeping or diapering that we should know?

Is there a special blanket or toy needed at naptime?(Required)

Yes

If yes, please describe

My child is enrolled in a Threes, PreK or Kaleidoscope class(Required)

Yes

Does your child nap?(Required)

Yes

Is your child right or left handed?(Required)

Right

Left

Undetermined

Does your child have any special fears?(Required)

Yes

If yes, how are you dealing with them?

Has your child had vision or hearing testing?(Required)

Yes

Remarks

General Information

What causes your child to show his/her temper?(Required)

How is temper displayed?(Required)

What method of behavior guidance is used in your home?(Required)

Please list the names of all children (include age and school) and adults living in the home, and state relationship to the child:(Required)

Does your child follow a daily routine?(Required)

Yes

How does your child react to a change in routine?(Required)

During the school year, is there a baby due?(Required)

Yes

Is a move planned?(Required)

Yes

Maybe

What pets do you have in your home?

Please include the type of pet and name; type n/a if none.

Has your child had experience in a playgroup?(Required)

Yes or no; include type of group

Has your child previously attended preschool?(Required)

Yes

If both parents are away from home during the day, please state arrangements for child’s care when not at school:(Required)

Have there been any family experiences that have influenced your child, such as a move, serious illness, extended guests in your home, or travel?(Required)

Do you have any other concerns that we should be aware of?

How would you describe your child’s temperament (easy going, slow to warm, etc)?(Required)

If you wish, tell us more about your child. Include any information that would be helpful to your child’s teacher.(Required)

Part 5 - Parent Permission and Payment of Fees Agreement

Health and Safety

Consent(Required)

· I give my consent for Day School staff to apply any of the following first aid products to my child as needed: antibiotic ointment, 1% hydrocortisone anti-itch cream, antiseptic wipe, latex-free bandage.

· I give my consent for information about my child’s allergies to be posted in the classroom, if applicable.

I agree

Exceptions to first aid products due to allergy:

Program Activities

Indoor & Outdoor Play Consent(Required)

· I give my permission for my child to use all play equipment and participate in all school activities.

· I give my permission for my child to participate in water activities using water tables and sprinklers.

I agree

Photo Consent(Required)

· I give my permission for photographs of my child to be used in the classroom, on the class Remind group messages (restricted access), and for SLDS use. (Children’s faces are not displayed on social media, and names are not attached to images outside the classroom.)

I agree

Tuition and Fees

Financial Consent(Required)

· I hereby agree to pay my child’s tuition on or before the first of each month. If I have provided payment information (ACH or credit card), I understand that tuition and fees will be charged according to the published schedule.

· I understand that a fee of $20 will be charged if my tuition payment is late (after the fifth of the month), and that my child may be asked to leave the program if the tuition is paid late thereafter.

· I understand a late fee of $20 will be charged for returned checks and declined ACH transactions.

· I understand that a fee of $1.00 per minute will be charged for late pick-up.

I agree

Publications(Required)

I give my consent for my child’s name, parents, and contact information (address, primary phone, primary email) to be published in the school directory. The directory is distributed to Day School families and staff only.

Yes

My signature verifies that all adults in my child’s family agree to the above terms for payment of fees and parent permission, and agree to comply with the rules and regulations of St. Luke’s Day School as outlined in the Family Handbook.

Signature(Required)

By typing my name below, I am acknowledging my signature of the Online Enrollment Form.

Date(Required)

MM slash DD slash YYYY