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
Format: (000) 000-0000.
Parent #2 Primary Phone Number
Format: (000) 000-0000.
Please indicate if you have subsidy.
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:
Admin of minor first aid procedures:
Walks and trips:
Wading:
Swimming:
Transportation by the facility:

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:
Parent/ Legal Guardian Name:
Child's First/Last Name:
Signature of Parent/ Legal Guardian:
Should be Empty:

Welcome!