Pre-Admission Background Information
Tell us more about your child!
Child's Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Nickname
Age
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Mother's Name
First Name
Last Name
Mother's Phone Number
Please enter a valid phone number.
Father's Name
First Name
Last Name
Mother's Work Phone
Please enter a valid phone number.
Mother's Occupation
Father's Business Phone
Please enter a valid phone number.
Father's Phone Number
Please enter a valid phone number.
Father's Occupation
Are parents together?
Are parents separated/divorced?
Is mother living?
Is father living?
Members of family/people living at home: Name, Age, Relationship, Indicated name used by child: Member 1
Members of family/people living at home: Name, Age, Relationship, Indicated name used by child: Member 2
Members of family/people living at home: Name, Age, Relationship, Indicated name used by child: Member 3
Members of family/people living at home: Name, Age, Relationship, Indicated name used by child: Member 4
Does your child have any disabilities?
If so, please state:
Does your child wear glasses?
Does your child wear a hearing aid?
Has your child had any previous school experience?
If so, please give name and type of school.
Length of attendance
Does your child take a nap?
Approximately how many hours does your child sleep at night?
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Is your child potty trained?
Word(s) child uses for potty:
Describe your child's appetite
Always hungry
Never hungry
Snacks
Snacks all day
Eats at meal time
Has to be coaxed to eat
Are there foods your child may not or cannot eat? (due to allergies, religion, customs, etc.)
Yes
No
If so, please state:
Are there any foods your child dislikes?
Yes
No
If so, please state:
Please select your child's interests
singing
painting
stories
trucks
pets
music
outside play
coloring
Other
Social Development: Is your child generally:
cooperative
shy
competitive
happy
aggressive
sensitive
submissive
angry
friendly
active
outgoing
Other
Does your child typically do what is asked of him/her?
Does your child:
whines
has tempertantrums
If so, how do you handle them:
Does your child have special fears?
How does your child respond to a stressful situation?
What seems to make your child feel better?
List other behavior characteristics of your child or anything else you would like us to know about your child:
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Emergency Information
Please help furnish the following emergency information. The information on this form is used to give emergency personnel if needed.
Date
-
Month
-
Day
Year
Date
Child's Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Father's Name
Father's Employer
Father's Work Phone
Please enter a valid phone number.
Father's Cell
Please enter a valid phone number.
Father's Email Address
Mother's Name
Mother's Employer
Mother's Work Phone
Please enter a valid phone number.
Mother's Cell Phone
Please enter a valid phone number.
Mother's Email address
Name of Emergency Contact #1 if parent(s) cannot be reached:
*
Emergency Contact # 1 Phone Number
*
Please enter a valid phone number.
Emergency Contact #1 Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Name of Emergency Contact #2 if parent(s) cannot be reached:
*
Emergency Contact #2 Phone Number
*
Please enter a valid phone number.
Emergency Contact # 2 Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Persons authorized to pick up child:
*
Allergies/Intolerance to food, medication, etc.
*
Child's Physician
*
Physician's Phone Number
*
Please enter a valid phone number.
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CHILD’S EMERGENCY MEDICAL AUTHORIZATION
The Parent(s)/Guardian(s) authorized Little Angels Montessori Preschool to obtain immediate medical care and consents to the hospitalization of, the performance of necessary diagnostic test upon, the use of surgery on, and/or the administration of drugs to, his/her child or ward if an emergency occurs when s/he cannot be located immediately. It is also understood that this agreement covers only those situations which are true emergencies and only when s/he cannot be reached. Otherwise, s/he expects to be notified immediately.
Please select the following
*
I/will be responsible for the payment of medical care expenses
Medical treatment costs will be covered by insurance listed below
No Insurance
Name of Insurance and Policy Number
Child's Physician/Clinic Attended
AUTHORIZATION FOR EMERGENCY TREATMENT
Permission for the Director, Acting Director, or the teacher to take whatever steps may be necessary for medical care in case of an emergency is hereby given. I understand that the order of actions taken will follow the outline below unless there is need for immediate action, but will not be limited to these actions:
Please check ALL of the following in case of an emergency.
*
Parent/guardian will be called.
Child's physician will be called
Contact persons listed will be called
If none of these efforts are successful, another physician will be called, an ambulance will be called, the child will be taken to the nearest emergency room accompanied by a staff member unless otherwise noted.
In order for the school to assume responsibility for my child, I understand that I must sign the child in at arrival and out at departure time.
Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit
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