Enrollment

PREFERRED START DATE *

CHILD NAME *

First

Last

CHILD NICKNAME *

CHILD ADDRESS *

CHILD DATE OF BIRTH *

CHILD AGE *

CHILD GENDER *

FATHER NAME *

First

Last

FATHER ADDRESS *

FATHER PREFERRED CONTACT TELEPHONE *

FATHER HOME TELEPHONE

FATHER WORK TELEPHONE

FATHER eMAIL *

FATHER EMPLOYER *

FATHER INFORMATION *

Responsible for Account
Child lives with
Emergency contact
Authorized pickup

Select all that apply.

MOTHER NAME *

First

Last

MOTHER ADDRESS *

MOTHER PREFERRED CONTACT TELEPHONE *

MOTHER HOME TELEPHONE

MOTHER WORK TELEPHONE

MOTHER eMAIL *

MOTHER EMPLOYER *

MOTHER INFORMATION *

Responsible for Account
Child lives with
Emergency contact
Authorized pickup

Select all that apply.

ALTERNATE PICKUP/EMERGENCY CONTACT 1 NAME *

First

Last

ALTERNATE PICKUP/EMERGENCY CONTACT 1 RELATIONSHIP *

ALTERNATE PICKUP/EMERGENCY CONTACT 1 ADDRESS *

ALTERNATE PICKUP/EMERGENCY CONTACT 1 PREFERRED TELEPHONE *

ALTERNATE PICKUP/EMERGENCY CONTACT 1 INFORMATION

Responsible for Account
Child lives with
Emergency contact
Authorized pickup

Select all that apply.

ALTERNATE PICKUP/EMERGENCY CONTACT 2 NAME *

First

Last

ALTERNATE PICKUP/EMERGENCY CONTACT 2 RELATIONSHIP *

ALTERNATE PICKUP/EMERGENCY CONTACT 2 ADDRESS *

ALTERNATE PICKUP/EMERGENCY CONTACT 2 PREFERRED TELEPHONE *

ALTERNATE PICKUP/EMERGENCY CONTACT 2 INFORMATION *

Responsible for account
Child lives with
Emergency contact
Authorized pickup

Select all that apply.

ALTERNATE PICKUP/EMERGENCY CONTACT 3 NAME *

First

Last

ALTERNATE PICKUP/EMERGENCY CONTACT 3 RELATIONSHIP *

ALTERNATE PICKUP/EMERGENCY CONTACT 3 ADDRESS *

ALTERNATE PICKUP/EMERGENCY CONTACT 3 PREFERRED TELEPHONE CONTACT *

ALTERNATE PICKUP/EMERGENCY CONTACT 3 INFORMATION *

Responsible for account
Child lives with
Emergency contact
Authorized pickup

Select all that apply.

HAS YOUR CHILD EVER BEEN IN DAYCARE? *

IF YES, WHERE AND HOW LONG?

WHY ARE YOU CHANGING DAYCARE CENTERS?

HAS YOUR CHILD BEEN DISMISSED FROM ANY CHILDCARE? *

IF YES, FOR WHAT REASON?

PLEASE SHARE ANY INFORMATION CONCERNING YOUR CHILD'S EXPERIENCE IN A GROUP SETTING (I.E, PLAY, EATING HABITS, SLEEP HABITS, SPECIAL FEARS, SPECIAL LIKES, OR SPECIAL DISLIKES)

HEALTH CARE NEEDS MEDICAL ACTION PLAN *

For any child with health care needs such as allergies, asthma, or other chronic conditions that require specialized health services, a medical action plan must be submitted with this application. The medical action plan must be completed by the child’s parent/guardian or healthcare professional. Please submit this plan prior to your child’s start date.

HEALTH CARE NEEDS KNOWN ALLERGIES *

Please list known allergies, the symptoms, type of response required for your child’s allergic reaction. If none, please enter NONE.

HEALTH CARE NEEDS CONCERNS *

Please list known health care needs or concerns, symptoms, and type of response for these needs/concerns. If none, please enter NONE.

HEALTH CARE NEEDS UNIQUE BEHAVIORS *

Please list any particular fears or unique behavior characteristics of your child. If none, please enter NONE.

HEALTH CARE NEEDS MEDICATIONS *

Please list any medication taken for health care needs. If none, please enter NONE.

HEALTH CARE NEEDS ADDITIONAL INFORMATION *

Please share any other information that has a direct bearing on assuring safe medical treatment for your child. If none, please enter NONE.

EMERGENCY MEDICAL CARE INFORMATION HEALTH CARE PROFESSIONAL NAME *

EMERGENCY MEDICAL CARE INFORMATION HEALTH CARE PROFESSIONAL TELEPHONE *

EMERGENCY MEDICAL CARE INFORMATION HEALTH CARE HOSPITAL PREFERENCE *

EMERGENCY MEDICAL CARE INFORMATION HEALTH CARE HOSPITAL PREFERENCE TELEPHONE *

MEDICAL RELEASE AUTHORIZATION *

I agree that Andrews Memorial Readiness School may authorize a physician of choice to provide emergency care in the event that neither I nor the family health care professional can be contacted immediately.

Andrews Memorial Readiness School agrees to provide transportation to an appropriate medical resource in the event of an emergency. In an emergency situation, other children in the facility will be supervised by a responsible adult. No drug or medication shall be administered without specific instructions from a physician or child’s parent, guardian, or full-time custodian. Provisions shall be made for your child’s adequate rest and outdoor play.

PARENTAL AGREEMENT SIGNATURE *

As a parent of a child registering for the upcoming year, I understand that the registration fee is non-refundable after I receive an acknowledgement from the administration accepting my child’s re-enrollment. Approved enrollment is based on space availability and scheduling of Andrews Memorial Readiness School director.

Hours & Info

Re-enrollment Due