Enrollment

Enrollment Registration
Date of Desired Enrollment

MonthDayYear
Date
Today's Date

MonthDayYear
Date
Full Name of Child
Students Birthdate

MonthDayYear
Date
Child's Primary Address
Parent #1 Contact and Place of Work Information
Parent #1 Full Name
Parent #1 Address
Primary Phone Number
Please enter a valid phone number.
Primary Phone Type

HomeWorkCell
Secondary Phone Number
Please enter a valid phone number.
Secondary Phone Type

HomeWorkCell
Email Address
example@example.com
Place of Work
Address of Work
Parent #2 Contact and Place of Work Information
Parent #1 Full Name
Parent #2 Address
Primary Phone Number
Primary Phone Type

HomeWorkCell
Secondary Phone Number
Secondary Phone Type

HomeWorkCell
Email Address
example@example.com
Place of Work
Address of Work
Persons to contact in case of emergency (if parents are not available) and/or authorized to pick up child.
Authorized Contact #1
Name #1
Relationship to Child
Home Phone Number
Please enter a valid phone number.
Work/Cell Number
Please enter a valid phone number.
Address
Emergency Contact

YesNo
Authorized to Pick Up

YesNo
Authorized Contact #2
Name #2
Relationship to Child
Home Phone Number
Please enter a valid phone number.
Work/Cell Number
Please enter a valid phone number.
Address
Emergency Contact

YesNo
Authorized Pick Up

YesNo
Authorized Contact #3
Name #3
Relationship to Child
Home Phone Number
Please enter a valid phone number.
Work/Cell Number
Please enter a valid phone number.
Address
Emergency Contact

YesNo
Authorized Pick Up

YesNo
Authorized Contact #4
Name #4
Relationship to Child
Home Phone Number
Please enter a valid phone number.
Work/Cell Number
Please enter a valid phone number.
Address
Emergency Contact

YesNo
Authorized Pick Up

YesNo
*Authorizations may be added/deleted at any time in written form.

*If emergency contact, an address MUST be listed.

***To confirm enrollment process, a non-refundable deposit, equivalent to one week’s rate is required, and will be applied to last week of enrollment.
Health Care Summary
Childs Physician
Type a question

Essentia Health 1027 Washington Ave, Detroit Lakes, MN 56501 218-847-2347Sanford Health 1245 Washington Ave, Detroit Lakes MN 56501 218-846-2000White Earth Clinic 40520 County Rd 34, Ogema, MN 56569 218-983-4300Other
Emergency hospital will default as:

Essentia Health @1027 Washington Ave Detroit Lakes, MN 56501, unless noted below.
Alternate Hospital
(full address and phone number required)
Child Dentist
Child Dentist Phone
Dentist Address
Dentist Default: Lakeridge Dental | 701 Corbett Road, Detroit Lakes, MN 56501 218-847-9214).
Insurance Company
Policy Number #
Are your child’s immunizations up to date

YesNo
If no, please explain
Note: Please attach copy of immunization record.

Cancelof
Does your child have any known health problems

YesNo
If yes, please attach documentation.

Cancelof
Please check below of any of the following illnesses your child has had
Child has had

MeaslesGerman MeaslesChicken PoxMumpsWhooping CoughOther
Childsuffers from frequent

HeadachesEarachesSore ThroatStomach AchesFlu/ColdsBloody NosesOther
Please list any injuries your child has had
Does your child have any known allergies

YesNo
If yes, what are they and what are your child’s reactions
Does your child take any medication on a regular basis

YesNo
If yes, please list the name of the medication(s) and the medical condition for which is taken
Doyou have any concerns about your child’s development

YesNo
If yes, please comment
Signature

Powered by Jotform SignClear
Date

MonthDayYear
Date
I authorize Laker Prep Preschool and Early Childhood Centers staff to obtain the following services for my child if necessary: public health nurse, physician, and/or ambulance in the event of an emergency. (Ambulance fees and/or health care costs are the responsibility of the family).

*The above information will not be disclosed to any person other than the child, the child’s parent/guardian, child’s legal representation, employees of license holder, and the commissioner unless the child’s parent/guardian has given written consent or as otherwise required by law.
Any Additional Information about your child.
Should be Empty:

Enrollment Registration

Health Care Summary