Bloom Fine Arts Preschool (Oak Ridge) Registration Form
2024-2025 School Year
Student Information
Full Name
*
Name to be called/written at school
*
Student Age
*
Date of Birth
*
Gender
*
Male
Female
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Phone Number
*
Please enter a valid phone number.
Previous Preschool/Childcare
(if applicable)
Child lives with
Both Parents
Dad
Mom
Other
If Other, please list name and relationship.
Name(s) & Age(s) of siblings
(write N/A if none)
Medical or Developmental Issues (allergies, hearing, eyesight, behavior, attention deficit, etc.)
(write N/A if none)
Mother/Guardian Information
Name
*
Email
*
example@example.com
Address (if different from child)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Phone
*
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Father/Additional Guardian Information
Name
*
Email
*
example@example.com
Address (if different from child)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Phone
*
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Authorizations & Releases
Emergency Contact Information: *In the absence of parents, child can be released to:
List up to 2 contacts other than parents (Name, Relationship to Child and Phone Number)
Child Pick up Authorization: *Other than Parents & Emergency Contacts
List up to 3 contacts other than parents (Name, Relationship to Child and Phone Number)
Is there a court order preventing anyone from picking up your child? (If a court order exists, Bloom will need to be provided with a copy to keep on file.)
Yes
No
Child's Doctor
*
Name and Phone Number
Preferred Hospital
*
Medical Insurance Company
*
Policy Number
*
I (here by) authorize Bullseye Entertainment Inc. dba Destination Arts/Bloom Fine Arts Preschool staff to secure medical attention for my child in case of serious illness or accident. I will assume full cost of said medical treatment and will not hold Bullseye Entertainment Inc. dba Destination Arts/Bloom Fine Arts Preschool financially responsible for these costs. I do (here by) release Bullseye Entertainment Inc. dba Destination Arts/Bloom Fine Arts Preschool, their staff and/or volunteers from any and all claim and liabilities of whatsoever nature, both individually and collectively, that may arise from my child participating in activities at Bullseye Entertainment Inc. dba Destination Arts/Bloom Fine Arts Preschool.
*
I allow Bullseye Entertainment Inc. dba Destination Arts/Bloom Fine Arts Preschool to use my child's name and photographic likeness in all forms and media for advertising, trade or any lawful purpose.
*
I understand that this is a full school year program and that I will be billed Sept-May on the 1st of each month. I understand that admission will be granted on a space available basis. I understand that I must submit the a health statement and immunization form by the first day of school. I understand that I can withdraw at any time, but no refunds will be made for withdrawals or absences.
*
Printed Name of the above signed
First Name
Last Name
Signature Date
-
Month
-
Day
Year
Preschool Class Options
Children entering our 3 and 4-year-old programs should be potty-trained. All classes meet from 9:00am until 12:00pm.
Please select one or BOTH the 2 and 3 day options if you want to attend 5 Days Per Week
*
2 Day Program - Tuesday & Thursday
3 Day Program - Monday, Wednesday & Friday
Registration Fee
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2024-2025 Registration & Supply Fee
$
125.00
Quantity
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Item subtotal:
$
0.00
Payment Methods
Debit or Credit Card
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the form.
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