'22-'23 TOWN OF WALLKILL CAMPUS: APPLICATION FOR ENROLLMENT

MEDICAL CONSENT, FACTS & HISTORY
In the event of medical emergency, I hereby authorize the transportation and or administration of any medical procedure deemed necessary by a doctor, or should doctor be unavailable, by any other physician or medical personel. I give OTM permission to us any over-the-counter topical ointment, sunscreen or topically applied insect repellent which I provide.
Signature *

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Allergies: *
Please write N/A if no known allergies
Medications:
List any ongoing chronic medications that might impact the child's wellbeing while at the preschool
Medical Conditions
Please list any existing medical conditions that may impact the child's health and well-being in the preschool
Limitations to physical activity
Please list any existing medical conditions that may restrict the child's physical activity in the preschool
Special equipment
Please list any orthodontic devices/prosthesis, glasses etc.
Special Diets
Any special diet/supplement that are medically prescribed should be included
Behavioral/Mental Health Issues
Please mention any behavioral conditions or mental health diagnoses eg. Autism, ADHD etc.
AUTHORIZATION & RELEASE FOR EPIPENS AND INHALERS
Please select the correct option

Epipen (select if your child may need an Epipen administered during school hours) Inhaler (select if your child may need an inhaler administered during school hours)
Directions for use
Please indicate dosage, frequency etc of Epipen
I, parent's name, parent/legal guardian of child's name request that the administration of the above noted medication be provided. I understand that the service will be provided by a person with no medical or nursing training. All training will be parent's responsibility. I agree to provide Over the Moon with an updated medical statement if there is any change in the physicians instructions with respect to medication. I hereby release Over the Moon, its employees and contractors from all manner of actions, causes of actions, lawsuits, damage or injuries, however caused, arising out of the administration or failure to administer medication as provided herein.SignatureDate

PHOTOGRAPHY: I give permission to the faculty and staff of Over the Moon to photograph my child. I understand these photographs may be posted on OTM's website or social media where they may be viewed by individuals other than school participants. *

I agree. I disagree.
TERMS & CONDITIONS: All students enrolled in our school are committing to our school year program, September - June. 30 days written notice must be given to withdraw and you are responsible for the tuition owed during that time. Upon acceptance into our program, the following are due: a non-refundable enrollment fee of $100 per student, a $100 security deposit per student, their first month’s tuition, along with the child’s up to date PHYSICAL & IMMUNIZATIONS. All such policies are outlined in the Family Handbook, which is always available on our website, www.otmenrichment.com. Over the Moon admits children and students of any race, color, national and ethnic origin to all the rights, privileges, programs, and activities generally accorded or made available to children and students at or through the organization. Over the Moon does not discriminate based on race, color, national and ethnic origin in the administration of educational policies, admissions policies, scholarship and loan programs and other organization-administered programs. *

I understand and agree to the above and all of OTM's policies and procedures.
Please include any notes, comments, questions or requests regarding your child and enrollment.
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Date *

Month Day Year
Signature *

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Student Information

Enrollment

Parent/Guardian Information

MEDICAL CONSENT, FACTS & HISTORY

AUTHORIZATION & RELEASE FOR EPIPENS AND INHALERS