Preschool Application

Date

New studentReturning student

Name

First NameMiddle NameLast Name

Gender

BoyGirl

Birthdate

Date

Home Address

Street Address

CityState / Province

Postal / Zip Code

Home Phone Number

Area CodePhone Number

Mom's Cell Number

Area CodePhone Number

Dad's Cell Number

Area CodePhone Number

Parent's Email

example@example.com

Mother's Name

First NameLast Name

Mother's Work Place

Mother's Occupation

Mother's Work Phone Number

Area CodePhone Number

Father's Name

First NameLast Name

Father's Work Place

Father's Occupation

Father's Work Phone Number

Area CodePhone Number

Emergency Contact Name

First NameLast Name

Relationship To Child (emergency contact)

Home Phone Number (emergency contact)

Area CodePhone Number

Cell Phone Number/2nd Phone (emergency contact)

Area CodePhone Number

Child's Personal Health #

Family Doctor

First NameLast Name

Doctor's Phone Number

Area CodePhone Number

Please list any medical concerns that the school needs to be aware of, including allergies, medications, psychological and/or physical special needs, learning disabilities:

Allergy Information

My child has NO allergies

My child DOES HAVE allergies that are NOT life-threatening

These non-life-threatening allergies include:

My child's allergies ARE LIFE THREATING

These life-threatening allergies include:

**If your child suffers from life-threatening allergies, it is essential that you complete the school’s Allergy Information Form(s) and personally inform your child’s teacher. It is the parent’s responsibility to provide guidance to the school with respect to the prevention of and treatment of allergic reactions. Please ensure that the school office and your child’s teachers have received specific instructions PRIOR to your child attending classes in September.**

Immunization Records

Please provide a photocopy of your child’s immunization booklet, confirming your child’s dates of immunization. Immunizations include PT/IPV/HIB (1 & 2), MR, DPTP, or QUAD (Kindergarten booster). Please note that children up to 6 years old are eligible for the Varicella (chickenpox) vaccine, unless they have already had the disease.

Privacy Act

I consent to have Bright Morning Star collect personal information that may include student identification information, birth certificate, legal guardianship records, court orders, parents’ work numbers and e-mail addresses, behavioral records, academic records, health information, most recent report card, emergency contact name and number, doctor’s name and number, health insurance number, and any similar information needed for registration.

I further consent to the use and disclosure of information contained in this form and otherwise collected by or on behalf of Bright Morning Star (1) for the purpose of establishing, maintaining, and terminating the student’s or parent’s relationship with Bright Morning Star (2) for additional purposes identified when or before personal information is collected, and (3) as otherwise provided in Bright Morning Star’s Personal Information Privacy Policy, a copy of which is available on request. I also consent to the collection, use, and disclosure of such personal information by and to Bright Morning Star's agents, contractors, and service providers.

This information is required in order to register your child at this school and assist the school authority in making an informed decision as to your child’s suitability and appropriate placement in the school. It will also allow the school to respond immediately to an emergency.

I consent to the following (please check applicable boxes below)

Class list (my child’s name, address, and phone number included on the “Class List” for his/her grade)Photographs and work samples of my child to be used in yearbook/scrapbookPhotographs and work samples of my child to be used in newsletter/website/promotional materialPhotographs and work samples of my child to be used in in-school parent presentation

Signature of Parent or Guardian

Date