Primrose Schools Enrollment Application and Agreement

PRIMROSE SCHOOLS ENROLLMENT APPLICATION AND AGREEMENT
GENERAL INFORMATION
STUDENT'S FULL NAME*
DATE OF APPLICATION*

MonthDayYear
Date
DATE OF ADMISSION

MonthDayYear
Date
MALEFEMALE
STUDENT'S DOB*

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
PARENT/GUARDIAN *
RELATION*
ADDRESS (If DIFFERENT THAN STUDENT'S)
MOBLE PHONE #*
WORK PHONE #*
EMAIL ADDRESS*
example@example.com
PARENT/GUARDIAN 2
RELATION
ADDRESS (IF DIFFERENT THAN STUDENT'S)
MOBILE PHONE #
WORK PHONE #
EMAIL ADDRESS
example@example.com
BOTH PARENTSMOTHERFATHEROTHER
SINGLEMARRIEDSEPARATEDDIVORCEDOTHER
"If court ordered custody must be followed, a copy of the decree must be maintained in the child's school file.
EMERGENCY INFORMATION

I authorize the school to release my child to leave the school ONLY with the following persons. Please list name phone number and relation for each. Children will only be released after verification of ID. Please indicate if each authorized pickup is also able to be contacted in an emergency in case parents cannot be reached.
EMERGENCY CONTACT/ AUTHORIZED PICKUP 1*
PHONE #*
RELATION*
EMERGENCY CONTACT ADDRESS*
EMERGENCY CONTACT/ AUTHORIZED PICKUP 2*
PHONE #*
RELATION*
YESNO
EMERGENCY CONTACT/ AUTHORIZED PICKUP 3
PHONE #
RELATION
YESNO
Should my child become ill or suffer an accident, I hereby authorize Primrose Schools to administer, call for, or secure the necessary emergency care of medical attention as deemed necessary by Primrose Schools. I understand that an effort will be made to contact myself or the designated persons. if possible, before any action is taken. I also understand that any expense incurred will be accepted by me.
NAME OF PHYSICIAN*
ADDRESS*
PHONE #*
EMERGENCY CARE FACILITY- TEXAS HEALTH ALLIANCE

ADDRESS: 10864 TEXAS HEALTH TRAIL, FORT WORTH, TX 76244

PHONE: 682.212.2000
EXCISTING MEDICAL CONDTION OR CHRONIC ILLNESSMEDICAITONS PRESCRIBED FOR CONTINOUS LONG-TERM USEPHYSICAL OR COGNITIVE CONDITIONS THAT MAY LIMIT OR RESTRICT CHILD'S ACTIVITIESOTHER
Explain any needs selected above (school may require a doctor's note or treatment plan. depending on severity of needs)
DIAGNOSED FOOD ALLERGY (requires a signed treatment plan by child's health care provider)DIETARY RESTRICTION/REGLIGIOUS PREFERENCE(requires a signed dietary restriction form by child's health care provider)DRUG ALLERGY
Please describe any above allergies
YESNO
YESNO
YESNO
YESNO
IF SO, PLEASE SPECIFY
YESNO
PLEASE DESCRIBE ANY PARTICULAR FEARS OR BEHAVIORS WE SHOULD BE AWARE OF
SCHOOL AGE CHILDREN
My child attends the following elementary school
School Phone #
MY CHILD'S REQUIRED IMMUNIZATIONS, VISION & HEARING SCREENING AND TB SCREENING (IF APPLICABLE) ARE CURRENT AND ON FILE AT THEIR SCHOOL.
Parent Initial
GENERAL AUTHORIZATIONS

I HEREBY GRANT PERMISSION FOR MY CHILD TO PARTICPATE IN THE FOLLOWING (PLEASE INITIAL EACH ITEM)
PROGRAM ACTIVITIES: All program activities, including the use of indoor and outdoor equipment.*
Parent Initials
WATER PLAY: Water related activities supervised by Primrose Schools including water tables, splash pads, and sprinkler play. Please note, Primrose Schools do not allow field trips to places with standing water such as pools, ponds, or lakes. *
Parent Initials
YESNO
ELEMENTARY SCHOOL TRANSPORT: Transport by Primrose Schools to and from the elementary school my child attends*
Parent Initials
FIELD TRIPS: Any scheduled field trips in age appropriate classes. I understand that will be provided and must complete written permission for each event in which I wish my child to participate. I will be given advance notice of such planned trips. I further understand that oral permission cannot be granted for field trip participation*
Parent Initials
GATED AREA: Permission is hereby granted for my child to leave the gated area for special reasons such as visits from fire fighters, observing plants on our campus, etc. Although they may leave the gated area, they will not leave the school campus and will always be supervised This will not involve the use of transportation. All actual field trips will have their own permission forms.*
Parent Initials
SUNSCREEN: I authorize Primrose staff to apply sunscreen to my child, for the protection from the sun when needed each day they attend. I understand that 1) I am to provide sunscreen labeled with my child's name, 2) Only the sunscreen I provide will be applied to my child and, 3) I, the parent/guardian, am to apply sunscreen in the morning before school and it will be applied again by my child's teacher after the rest period in the afternoon.*
Parent Initials
INTERNET USAGE: I acknowledge that my child will have access to the Internet through Primrose approved pathways only (e.g.. learning applications and student assessment programs for Preschool, Pre-K and Explorer students), and under teacher supervision at all times. I understand that even with the precautions taken by this school, exposure to inappropriate materials may accidentally occur. I agree to indemnify, defend, and hold harmless Primrose Schools, its employees, and agents from any and all claims, demands, actions, liabilities, and expenses, arising from or related to my child's use of the Internet and hereby walve, release, and discharge, any and all claims I may have against Primrose Schools and its affiliates arising from my child's use of the internet and the use thereof by Primrose Schools' teachers, administrators, officers, employees, and other students. With that understanding, I hereby give permission to Primrose Schools to allow my child to have access to the Internet under these stated conditions. (Preschool, Pre-K and Explorer students only)*
Parent Initials
I agree that I have read and understand the terms and agreements listed herein. I am in receipt of and agree to comply with all policies and procedures set forth in the Primrose Schools Parent Handbook and Addendums and agree to the provisions which are incorporated herein, by reference and are a part hereof.
Parent/Guardian Signature*

Powered by Jotform SignClear
Date*

MonthDayYear
Date
Parent/Guardian Signature

Powered by Jotform SignClear
Date

MonthDayYear
Date
Should be Empty:

PRIMROSE SCHOOLS ENROLLMENT APPLICATION AND AGREEMENT

GENERAL INFORMATION

EMERGENCY INFORMATION

SCHOOL AGE CHILDREN

GENERAL AUTHORIZATIONS