Pre-K Registration 2024

pre-k Registration
CIRCLES OF SUCCESS LEARNING ACADEMY-PREK REGISTRATION FORM-2024/2025
PERSON COMPLETING THIS FORM
CHILD'S FIRST NAME:
Name

CHILDS FIRST NAMECHILDS LAST NAME
CHILD'S MIDDLE NAME:
Name Suffix (ie, Jr, Sr, II, III)
CHILD'S SOCIAL SECURITY#:
D.O.B. (MM/DD/BY):
SEX: M F

MaleFemale
Address

Street Address

County

CityState

Zip Code
Phone Number
Please enter a valid phone number.
If the Student is transferring from another Pre-K, please provide the following: Previous School Name: Last Date in Attendance:
Previous School Name
Last Date in Attendance

MonthDayYear
Date
Parent/Guardian #1
First Name
Middle Name
Last Name
Home Address If different from child

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Email Address
example@example.com
Place of Employment:
Work Phone:
Please enter a valid phone number.
Work Address

Street Address

Street Address Line 2

CityState / Province

Zip Code
Parent/Guardian #2
First Name
Middle Name
Last Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Email
example@example.com
Place of Employment
Work Phone
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
EMERGENCY CONTACT INFORMATION (Persons to contact in the event that either parent/guardian cannot be contacted)

NAME RELATIONSHIP CELL PHONE ALTERNATE PHONE EMAIL
Name 1

Full NameRelationship
Cell Phone or Alternative Phone
Please enter a valid phone number.
Email
example@example.com
Name 2

Full NameRelationship
Cell Phone or Alternative Phone
Please enter a valid phone number.
Email
example@example.com
I verify the above information to be correct, and I understand that completion of this form does not guarantee placement in a Pre-K class. If my child is placed in COSLA's Pre-K Program, I agree that my child will attend the program for the required number of hours and days as prescribed by the Tennessee Department of Education and outlined by COSLA where my child is enrolled. I understand that failure to comply with these attendance requirements could result in disenrollment. I understand that I cannot register my child without appropriate age documentation. I have attached a copy of appropriate age documentation to this registration form.

Signature Parent/Guardian: DATE:
Signature

Clear
Date

MonthDayYear
Date
CHILD'S LIVING ARRANGEMENTS

Both ParentsMotherFatherOther
CHILD'S LEGAL GUARDIAN:

Both ParentsMotherFatherOther
THE CHILD MAY BE RELEASED TO THE PERSONS SIGNING THIS AGREEMENT OR TO THE FOLLOWING: NAME ADDRESS RELATIONSHIP CELL PHONE
Person 1

Full NameAddress
RelationshipCell Phone
Person 2

Full NameAddress
RelationshipCell Phone
Person 3

Full NameAddress
RelationshipCell Phone
Person 4

Full NameAddress
RelationshipCell Phone
CHILD'S PHYSICIAN OR CLINIC'S NAME (CHILD'S PRIMARY HEALTH SOURCE)

Name Phone
DATE OF LAST FULL HEALTH SCREENING

MonthDayYear
Date
MY CHILD HAS THE FOLLOWING SPECIAL NEEDS / ALLERGIES 1
MY CHILD HAS THE FOLLOWING SPECIAL NEEDS / ALLERGIES 2
MY CHILD HAS THE FOLLOWING SPECIAL NEEDS / ALLERGIES 3
THE FOLLOWING SPECIAL ACCOMMODATIONS MAY BE REQUIRED TO MOST EFFECTIVELY MEET MY CHILDS NEEDS WHILE AT THIS ACADEMY 1
THE FOLLOWING SPECIAL ACCOMMODATIONS MAY BE REQUIRED TO MOST EFFECTIVELY MEET MY CHILDS NEEDS WHILE AT THIS ACADEMY 2
MY CHILD IS CURRENTLY ON MEDICATIONS PRESCRIBED FOR LONGTERM CONTINUOUS USE AND / OR HAS THE FOLLOWING PREEXISTING ALLERGIES ILLNESS OR HEALTH CONCERNS 1
MY CHILD IS CURRENTLY ON MEDICATIONS PRESCRIBED FOR LONGTERM CONTINUOUS USE AND / OR HAS THE FOLLOWING PREEXISTING ALLERGIES ILLNESS OR HEALTH CONCERNS 2
Note: The following documents will be needed before enrollment is granted:

Parent ID (Driver's License)

*Two Proofs of Residence - see acceptable proofs below

Certified (state stamped) Birth Certificate (Not mother's copy)

TN Certificate of Immunization (current)

Proof of physical (current)

Proof of Income (W2 form)

Your child must be 4 years of age on or before August 15, 2021

*Acceptable Proofs of Residence include:

Valid Driver's license

Municipal water bill

Lease or Rental Agreement

Public Assistance/government benefits letter

Real estate tax receipt

Mortgage statement or deed

Military housing agreement
SIGNATURE Parent / Guardian

Clear
I verify the above information to be correct and true. I hereby grant permission for the information provided in the preceding Registration Form to be distributed to COSLA's Pre-K providers, and certain agencies or those entities contracted by the Academy's Pre-K providers, which shall include, but not be limited to, the Tennessee Department of Education, and colleges/universities.
DATE

MonthDayYear
Date
Should be Empty:

pre-k Registration

CIRCLES OF SUCCESS LEARNING ACADEMY-PREK REGISTRATION FORM-2024/2025

CHILD'S FIRST NAME:

THE CHILD MAY BE RELEASED TO THE PERSONS SIGNING THIS AGREEMENT OR TO THE FOLLOWING: NAME ADDRESS RELATIONSHIP CELL PHONE