Bilingual Immersion Prepatory Academy

Bilingual Immersion Prepatory Academy

Pre-Registration Form
Welcome!

Please fill out this pre-registration form to be considered for one of our toddler or preschool full-time spaces. After this form is submitted, we will contact you to schedule an interview to meet your lovely family! We will discuss your childcare needs and our philosophy.
Parent/ Legal Guardian #1 Name*

First NameLast Name
Parent/ Legal Guardian #2 Name

First NameLast Name
Child's Name*

First NameMiddle NameLast Name
Child's Birth Date*

MonthDayYear
Child's Gender*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Primary E-mail*
example@example.com
Secondary E-mail
(optional)
Parent #1 Primary Phone Number*
Parent #2 Primary Phone Number
Please indicate if you have subsidy.*

YesNo
Personality and preferences:
Please indicate full-time or preferred schedule:

Medical Information
Date of child's most recent physical exam:
Please upload child's most recent physical:

Cancelof
See link below for printable health form:
Health insurance coverage for child or medical assistance benefits:
Policy # for Health insurance coverage or medical assistance benefits:
Name of child's physician/ medical care provider:
Address and telephone # of child's Physician/ medical care provider:
Allergies including medication reactions:
Health and development history:
Any significant injuries, hospitalizations, or developmental concerns.

Medication, special conditions or disabilities:
Medical or dietary information necessary in an emergency situation:
Permissions

Parent's/Legal Guardian's signature is required for each item below to indicate parental consent:
Obtaining emergency medical care:

Powered by Jotform SignClear
Admin of minor first aid procedures:

Powered by Jotform SignClear
Walks and trips:

Powered by Jotform SignClear
Wading:

Powered by Jotform SignClear
Swimming:

Powered by Jotform SignClear
Transportation by the facility:

Powered by Jotform SignClear

Consent for Use of Media

We love to capture the day-to-day activities, special events, and learning experiences of our students. The media we collect helps us celebrate your child's progress and share updates with families.
Authorization and Release:

I, the undersigned parent or legal guardian, do hereby give my consent for my child to be photographed, video recorded, or audio recorded during normal daycare activities, including in the classroom and during field trips.
I authorize Bilingual Immersion Prepatory Academy to use, edit, copy, and publish these media for the following purposes:Please select one of the following options:

FULL PERMISSION- I give full permission for my child's media to be used for purposes, including, but not limited to: the center's private communication app or newsletters, displaying in the classroom or center, on the center's public website and social media pages, in promotional and marketing materials (e.g., brochures).LIMITED PERMISSION- I give limited permission for my child's media to be used for internal purposes only. This means the media may be used in the center's private communication app or displayed inside the classroom, but will not be used on any public-facing materials, including the website or social media.NO PERMISSION- I do not give permission for my child to be photographed, video recorded, or audio recorded for any purpose other than for use by staff for internal learning and communication.
Parent/ Legal Guardian Name:
Child's First/Last Name:
Signature of Parent/ Legal Guardian:

Powered by Jotform SignClear
Should be Empty:

Bilingual Immersion Prepatory Academy

Welcome!

Medical Information

Permissions

Consent for Use of Media

Authorization and Release: