Beruflich Dokumente
Kultur Dokumente
Dear Parents,
Please take the time to fill out the 2010-2011 registration packet
and submit it with your $50.00 registration fee to hold your child’s
place in the Weekday School. Open spaces are filled on a first
come, first served basis. In order to assure your child’s place in
the Weekday School, it is recommended that you submit the
registration forms and fees as soon as possible.
Address ________________________________________________________________
Address ________________________________________________________________
Please list any medical conditions that we should be aware of (allergies, asthma, diabetes,
etc) ____________________________________________________________________
Does your child get along well with other children? ___________
Is there anything else you would like to share about your child?
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PHYSICAL EXAMINATION
(Must be completed and signed by the examining physician)
Recommendations: ___________________________________________
VACCINE #1 #2 #3 #4 #5
DTP/DT
Polio xxxxxxxxx
HiB xxxxxxxxx
Hepatitis B xxxxxxxxxx xxxxxxxxx
MMR xxxxxxxxxx xxxxxxxxxx xxxxxxxxx
Chicken Pox
Prevnar
Other
_________________________________________ ________________________
Physician’s Signature Date of Examination
_________________________________________ ________________________
Office Address Telephone Number
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Medical History
1. Is your child allergic to anything? Yes _____ No _____
If so, what? ________________________________________________________
2. Has your child had a serious illness, surgery or hospital stay? Yes _____ No _____
If so, please describe: ________________________________________________
3. Does your child have any physical handicaps? Yes _____ No _____
If so, please describe: ________________________________________________
4. Is your child currently under the care of a Doctor? Yes _____ No _____
If so, for what reason? _______________________________________________
6. Does your child have frequent cold ____; coughs ____; tonsillitis ____;
ear infections ____; upset stomach ____; high fever ____ ?
Medical Information
Name of child’s Doctor ________________________________ Phone ____________
Office Address ___________________________________________________________
Emergency Contact
If neither the father nor mother (Legal Guardian) can be reached, call:
I agree that the director may authorize the physician of his/ her choice to provide
emergency care in the event that neither the family physician nor I can be contacted
immediately. This is done with the understanding that every attempt will have been
made to contact the parents, the child’s physician and other persons listed for emergency
contact.
______________________ __________________________________________
Date Signature of parent or guardian
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Initial
Address ______________________________________________________
_____________________________________________________________
City State Zip Code
In case of emergency, please list two people who can be contacted if you
cannot be reached.
Name of person(s) that are allowed to pick-up Child on regular basis _____
_____________________________________________________________
_____________________________________________________________
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Date _________________________________________________________
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We ask that each child in the 3, 4-year old and Stepping Stones classes
purchase a school t-shirt. These will be worn on field trips. Everyone is welcome
to purchase a shirt! We have adult sizes too! T-shirt order forms are included
and should be returned with registration fees. Returning students that already
have t-shirts do not need to purchase new ones unless they would like to! Thank
you in advance!