Child's Pre-Admission Record 2024/2025

CHILD'S PRE-ADMISSION RECORD

2024/2025 SCHOOL YEAR ENROLLMENT
This section is to be completed by the child's parent or guardian. This form must be kept in the child's file in the school.
DATE*

MonthDayYear
CHILD'S DATE OF BIRTH*

MonthDayYear
CHILD'S NAME*

First NameMiddle (optional)Last Name
NAME CHILD IS KNOWN BY*
HOME ADDRESS*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
MOTHER'S NAME (OR FIRST GUARDIAN)*

First NameLast Name
MOTHER'S CELL*
MOTHER'S EMAIL*
MOTHER'S EMPLOYER
MOTHER'S EMPLOYER PHONE
MOTHER'S EMPLOYER'S ADDRESS

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
FATHER'S NAME (OR SECOND GUARDIAN)*

First NameLast Name
FATHER'S CELL*
FATHER'S EMAIL*
FATHER'S EMPLOYER
FATHER'S EMPLOYER PHONE
FATHER'S EMPLOYER'S ADDRESS

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
EMERGENCY PROCEDURES
INSTRUCTIONS REGARDING HOW TO REACH THE PARENTS OR GUARDIANS IN CASE OF AN EMERGENCY*
NAME OF FIRST PERSON TO CONTACT IN AN EMERGENCY IF PARENT/GUARDIAN CANNOT BE REACHED*

First NameLast Name
RELATIONSHIP TO CHILD*
PHONE OF FIRST PERSON*
ADDRESS OF FIRST PERSON*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
NAME OF SECOND PERSON TO CONTACT IN AN EMERGENCY IF PARENT/GUARDIAN CANNOT BE REACHED

First NameLast Name
RELATIONSHIP TO CHILD
PHONE OF SECOND PERSON
ADDRESS OF SECOND PERSON

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
NAME OF THIRD PERSON TO CONTACT IN AN EMERGENCY IF PARENT/GUARDIAN CANNOT BE REACHED

First NameLast Name
RELATIONSHIP TO CHILD
PHONE OF THIRD PERSON
ADDRESS OF THIRD PERSON

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
NAME OF CHILD'S DOCTOR*

First NameLast Name
DOCTOR'S PHONE*
DOCTOR'S OFFICE ADDRESS*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
EMERGENCY AUTHORIZATION

By adding my electronic printed signature below, I give permission for the school to obtain emergency medical treatment, including emergency transportation for my child, if I cannot be reached immediately. I agree to be responsible for any emergency medical expenses incurred. (If a parent/guardian refuses to sign, instructions must be added below stating what procedure the school is to follow in an emergency.)
PARENT/GUARDIAN NAME*

First NameLast Name
SIGNATURE OF PARENT/GUARDIAN

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IF YOU DO NOT SIGN THE ABOVE TO OBTAIN EMERGENCY MEDICAL TREATMENT, DESCRIBE INSTRUCTIONS STATING WHAT PROCEDURE THE SCHOOL IS TO FOLLOW IN AN EMERGENCY.
PERSONS THE CHILD MAY BE RELEASED TO
NAME OF FIRST PERSON CHILD MAY BE RELEASED TO*

First NameLast Name
RELATIONSHIP TO CHILD*
PHONE OF FIRST PERSON CHILD MAY BE RELEASED TO*
ADDRESS OF FIRST PERSON CHILD MAY BE RELEASED TO*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
NAME OF SECOND PERSON CHILD MAY BE RELEASED TO

First NameLast Name
RELATIONSHIP TO CHILD
PHONE OF SECOND PERSON CHILD MAY BE RELEASED TO
ADDRESS OF SECOND PERSON CHILD MAY BE RELEASED TO

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
NAME OF THIRD PERSON CHILD MAY BE RELEASED TO

First NameLast Name
RELATIONSHIP TO CHILD
PHONE OF THIRD PERSON CHILD MAY BE RELEASED TO
ADDRESS OF THIRD PERSON CHILD MAY BE RELEASED TO

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
NAME OF FOURTH PERSON CHILD MAY BE RELEASED TO

First NameLast Name
RELATIONSHIP TO CHILD
PHONE OF FOURTH PERSON CHILD MAY BE RELEASED TO
ADDRESS OF FOURTH PERSON CHILD MAY BE RELEASED TO

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
PERMISSIONS FOR ACTIVITIES
I GIVE MY PERMISSION FOR MY CHILD TO PARTICIPATE IN ACTIVITIES AWAY FROM THE SCHOOL.*

YesNo
I GIVE MY PERMISSION FOR MY CHILD TO PARTICIPATE IN TRANSPORTATION PROVIDED BY THE SCHOOL.*

YesNo
I GIVE MY PERMISSION FOR MY CHILD TO PARTICIPATE IN SWIMMING/WADING ACTIVITIES PROVIDED BY THE SCHOOL.

YesNo
I WISH TO HAVE MY CONTACT INFORMATION PUBLISHED IN THE SCHOOL DIRECTORY. (THIS SECTION IS PASSWORD PROTECTED AND NOT AVAILABLE TO THE GENERAL PUBLIC).

YesNo
SIGNATURE OF PARENT/GUARDIAN*

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NAME OF PERSON FILLING OUT THIS FORM*

First NameLast Name
RELATIONSHIP TO CHILD*
Should be Empty:

CHILD'S PRE-ADMISSION RECORD