Oak Brook School Murphy Enrollment Paperwork

Child Information
Child's Name*

First NameLast Name
Child's Date of Birth*

MonthDayYear
Child's Address*

Street Address

Street Address Line 2

CityState

Zip Code
With whom does the child live?*
What days and hours will your child be in care?*
Child's Start Date*

MonthDayYear
Medical History
Please list any special needs or problems your child may have, such as allergies, existing illness, previous serious illness, injuries during the past 12 months, any medications prescribed for long long-term use, and any other information that staff should know of.
Food Allergies
Requires a Food Allergy Emergency Plan
Dietary Restrictions
(e.g. vegetarian)

Parent Information
Parent #1 Name*

First NameLast Name
Parent #1 Email*
example@example.com
Parent #1 Cell Phone Number*
Please enter a valid phone number.
Parent #1 Relationship to Child*
Parent #1 Place of Employment*
Parent Address

Street Address

Street Address Line 2

CityState

Zip Code
Parent #2 Name

First NameLast Name
Parent #2 Email
example@example.com
Parent #2 Cell Phone Number
Please enter a valid phone number.
Parent #2 Relationship to Child
Parent #2 Place of Employment

Emergency Contact and Physician Information
*Emergency Contact must be someone other than a parent or guardian*
Emergency Contact Name*
Emergency Contact Name:
Emergency Contact Phone Number*
Please enter a valid phone number.
Emergency Contact Relationship to Child*
Emergency Contact Address*
Physician Name*
Physician Phone Number*
Physician Address*

Child Permissions and Authorizations
Photo Permission*

I do give permission to OBS to take and use my child's picture on ProcareI do not give permission to OBS to take and use my child's picture
Additional Photo Permission

I give permission to OBS to use my child's picture on FacebookI give permission to OBS to use my child's picture for Marketing
Parent Initials*
Field Trip Permission: (5 years of age and above)

I do hereby give permission for my child to attend all field trips planned. I realize that the Oak Brook staff will do everything in their power to protect my child during these field trips. However, I/we will not hold them responsible for accidents. I also understand that my child will be transported on the Oak Brook School bus.
Parent Initials
General Transportation:

I do hereby give permission for my child to be transported by Oak Brook School.

I understand that the Oak Brook staff will do everything in their power to protect my child during transport. However, will not hold them responsible for accidents.
Home Address (in case of emergency only)*
Home Address
Field Trip Destinations ( Explorer/KJS age groups only)*
Field Trip Destinations
Elementary School Name*
Elementary School Address
Elementary School Phone Number
Please enter a valid phone number.
Parent Initials
Authorization for emergency medical attention:

I give my consent for necessary emergency treatment when my child is in the care of their physician and/or hospital/clinic.

I authorize Oak Brook School to make the decision to transport my child by way of an emergency ambulatory service. I agree that this service will be at my expense. I agree to not hold Oak Brook School responsible for the actions of said emergency personnel.
Parent Initials*
Parent Initials*
Release of Children:

Oak Brook School will not release a child to any person other than a parent unless previously notified by the parent. I understand that I must notify the school in advance if anyone other than the child's parent is to pick up. Please list any individual who is authorized to pick up your child.
Parent Initials*
Authorized Pickup #1
Authorized Pickup Phone Number
Please enter a valid phone number.
Additional Pickup Relationship to Child
Authorized Pickup #2
Authorized Pickup Phone Number
Please enter a valid phone number.
Additional Pickup Relationship to Child
Authorized Pickup #3
Authorized Pickup Phone Number
Please enter a valid phone number.
Additional Pickup Relationship to Child
Summer Sunscreen and Insect Repellant: (All Children)

I acknowledge that during the summer program, Oak Brook School will provide sunscreen. If will be applied each time the children go outside and for water time. We will use clear continuous spray SPF 50 sunscreen. Insect repellant will be applied per parent request; parent must bring insect repellant.
Parent Initials*
Water Activities Permission: (All Children)*

I have independently tested and affirm my child's swimming skills level. (Please fill out the Water Activity Permission Form also)I do attest my child is able to independently swim 25 yards.I do not give permission for my child to participate in water activities at Oak Brook School
Parent Initial

Medical Information
Child's Name

First NameLast Name
Child's Date of Birth

MonthDayYear
Physician Statement of Health:

I have attached or sent a statement of health signed by a health-care professional indicating my child is able to take part in the child-care program.
Physician Statement Upload

Cancelof
Immunizations:

I am excluding my child from the immunization requirement for reasons of conscience, including a religious belief. I will provide a valid vaccine exemption affidavit form developed and issued by the Department of State Health Services. I understand that this affidavit is valid for 2 years from the date notarized and must be resubmitted every two years.I have my child's current immunzation record. An updated copy must be provided to the school every time immunizations are updated.My child attends public/private school away from the day care operation and the immunization is on file at the school.
Immunization Record Upload

Cancelof
School's Name
School's Phone Number
School's Address
Vision and Hearing Screening: (ages 4 and above)

I have attached or sent a current copy of my child's vision and hearing results. These screenings are typically done during a 4-year-old well check.
Vision and Hearing Screening Upload

Cancelof
Nutrition:

According with state minimum standards your child will be served a nutritionally balanced lunch every day. If the posted menu for the day does not work with your child's food allergies or restrictions it will be your responsibility to send in a replacement meal/snack for that day. If you choose to bring lunch for your child, you are taking responsibility for your child's nutritional needs. Nut free school. A vegetarion option is always available as well.
Parent initial*
Medication:

In an effort to keep kids healthy and free of illness, Tylenol and Ibuprofen will not be administered without a doctor's note since if may mask symptoms of illness. Medications must be original packaging age specific and are administered only at 12:00pm and 4:00pm.
Parent initial*
Signature of Parent or legal Guardian*

Clear
Date Signed*

MonthDayYear

Tuition Contract
Tuition Contract
Child's Name

First NameLast Name
Parent's/Signature*

Clear
Date Signed*

MonthDayYear
Parent Handbook Acknowledgment
I have read and fully understand the policies and procedures set forth in the Oak Brook School Parent Handbook. In addition, I have received a printed or electronic copy of the Handbook for my personal reference.
Printed Name Parent or Guardian*
Signature of Parent or Guardian*

Clear
Date Signed*

MonthDayYear

Homework Agreement for Explorers
This homework agreement for explorers at Oak Brook school is between a parent and his/her child. Any changes to this agreement should come from the parent and will be do our best to enforced by the school.
Homework Agreement

No, I do not want my child to do his/her homework at Oak Brook School. He/she will do it at home.Yes, please have my child do his/her homework at Oak Brook School. Know that this will take place from 4:00pm - 4:45pm Monday - Thursday.
- I understand this is an agreement between myself and my child.
- I understand that it is my child's responsibility to get their homework when they are asked; teachers will not check backpacks and folders for
- I understand that the Oak Brook teachers will do their best to help and assist with all homework in the allotted time, but it is my responsibility to check my child's homework for accuracy and completeness.
- Required reading is best done at home where the environment is quieter for retention and comprehension.
Parent's Signature

Clear
Date Signed

MonthDayYear
Child's Name
Date

MonthDayYear
Should be Empty:

Child Information

Parent Information

Emergency Contact and Physician Information

Child Permissions and Authorizations

Medical Information

Tuition Contract

Parent Handbook Acknowledgment

Homework Agreement for Explorers