Juniper Student Information Form
Child's Full Name
*
First Name
Last Name
DOB
*
-
Month
-
Day
Year
Date
Medical/Health/Behavior Concerns or things to know
*
Child Immunization
*
The School has a hard copy
The School has an electronic copy
I can upload one below
Child Immunization Form or Exempt Form
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Family Information
Parent #1 Full Name
*
First Name
Last Name
Parent #1 Email
*
example@example.com
Parent #1 Phone
*
-
Area Code
Phone Number
Parent #1 Employer Name & Phone Number
*
Parent #1 Employer Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent #2 Full Name
*
First Name
Last Name
Parent #2 Email
*
example@example.com
Parent #2 Phone
*
-
Area Code
Phone Number
Parent #2 Employer Name & Phone Number
*
Parent #2 Employer Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Family Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Family Physician
*
Physician Phone
*
-
Area Code
Phone Number
Family Dentist
*
Dentist Phone
*
-
Area Code
Phone Number
Family Insurance Provider
*
Insurance Provider Phone
*
-
Area Code
Phone Number
Additional authorized persons to drop off and pick up your child.
*
Full Name, Relation to child & Phone Number
Does your family qualify for the Free & Reduced Program?
*
Yes
No
Maybe
Link to Apply: http://www.durangoschools.org/apps/pages/index.jsp?uREC_ID=511926&type=d&pREC_ID=1033532
If your family qualifies for the Free & Reduced Program, please upload a copy of your letter here. Or you can email to niftynannydgo@gmail.com or you can bring in a hard copy to the front office.
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Terms and Conditions
Medical Consent
*
I agree
CONSENT FOR MEDICAL TREATMENT: As the parent or legal guardian of the above-named participant, I hereby give my consent for emergency medical care prescribed by a duly licensed Doctor. I give Nifty Nanny Personnel permission to take the above-named participant to the nearest medical facility to receive emergency medical care. This care may be given under whatever conditions are necessary to preserve the life, limb, or well-being of my dependent.
Liability Releasae
*
I agree
COMPLETE RELEASE OF LIABILITY : As the parent or legal guardian of the above-named participant, I hereby release Nifty Nanny, LLC and all staff from liability of any accident, illness, injury or even death that could occur from daily activities at all Nifty Nanny programs.
Juniper Club Waivers
*
Yes
No
Sunscreen Application: As the parent or legal guardian of the above-named participant, I hereby give my consent for Nifty Nanny staff to apply sunscreen on my child.
Consent for Snacks: As the parent or legal guardian of the above-named participant, I hereby give my consent for the participant to receive snacks from Nifty Nanny staff while attending Juniper Club.
Consent for Movie: As the parent or legal guardian of the above-named participant, I hereby give my consent for the participant to watch rated G or PG movies.
Consent for Photos: Our Nanny's are actively engaged in fun activities during our Programs with your children. During which time, our team like's to snap photos of the fun. Do you give consent for our Company to use photos from our time with your family for marketing and social media posting on all of our Nifty Nanny & Juniper Club social media platforms.
E-Signature Agreement to attest all of the information you provide is the most up to date and correct information.
Submit Student Form
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