STARS Preschool Registration Form

STARS Preschool Registration Form
Return registration to:

Option 1: Complete registration on Jot Form

Option 2:

Irondequoit Site Manager Abigail Lagoner alagoner@liberty-resources.org

585-417-5181

Webster Site Manger Christina Werts cwerts@liberty-resources.org

585-545-4861

Option 3: Fax to our main office at 585-697-5692
Childs Name*
DOB*
Nickname*
Gender*
Height*
Weight*
Address*
Primary phone*
School District*
Primary language other than English
Diagnosis (N/A or if yes, please explain)*
Allergies (N/A or if yes, please explain)*
Asthma (N/A or if yes, please explain)*
Medications (N/A or if yes, please explain)*
Medical Alerts (N/A or if yes, please explain)*
Will your child require any medication or medical treatment while at school?*

YesNo
If yes, please explain: *A health care plan will need to be completed by you and the doctor prior to your child attending school. (Liberty POST administers Epi-pen meds only)
Parent/Guardian Name*
Cell phone*
Home phone
Address*
Email*
example@example.com
Work Place*
Phone*
Preferred method(s) of contact(check all that apply) :*

emailphonetextmail
Parent/Guardian Name*
Cell phone*
Home Phone
Address*
Email*
example@example.com
Work Place*
Phone*
Preferred method(s) of contact(check all that apply) :*

emailphonetextmail
Parent/Guardian Status:*

marriedsingleseparateddivorced
Please select if information is requested to be shared with both households:

YesNo
Sole/Joint Custody with: *please provide legal documentation upon enrollment*
Pediatric Group*
Doctor's Name:*
Phone*
Address*
Fax*
Medical Insurance*
Hospital*
Emergency Contacts:

STARS Preschool/Liberty Post has permission to contact those listed below in case of an emergency when parents cannot be reached and we, along with the transportation company, are authorized to release your child into the custody of: (minimum of 3 required)
1. Emergency Contact Name*
1. Relationship to child*
1. Cell Phone Number*
2. Emergency Contact Name*
2. Relationship to child*
2. Cell phone Number*
3. Emergency Contact Name*
3. Relationship to child*
3. Cell phone number*
4. Emergency Contact Name
4. Relationship to child
4. Cell Phone Number
Consent for Exchange of Information

In order to provide complete services to your child, it may be necessary to request copies of evaluations, examinations, observations or therapy notes from other agencies or professionals who have previously and/or who currently serve your child. Also, other agencies or professionals may request STARS Preschool updates regarding your child. Your written permission is required to share this information. You may also give us permission to share information about your child's progress with family members or other caregivers. Be assured that only those you provide consent for will receive reports and that great care is taken to safeguard your child's privacy.
Childs Name*
Date of Birth*

MonthDayYear
Date
I authorize Liberty POST/STARS Preschool staff to exchange verbal & written information, including but not limited to, medical reports, evaluations & progress notes, regarding my child via (check all that apply):*

phonefaxemailtext
Pediatrician/Other Medical Personnel Name**MUST SUPPLY THIS INFORMATION***
Address*
Phone/Fax number*
Daycare, Caregiver, Nanny Name:
Address
Phone/Fax number
Non- Liberty POST/STARS Preschool Service Provider Name:
Address
Phone/Fax number
Consent to exchange information*

District Committee on Special Education (CSE) staff & District Committee on Preschool Special Education (CPSE) staff
Other (for example family member) Name:
Address
Phone/Fax number
Signature*

Clear
Relationship to child*
Date*

MonthDayYear
Date
Email*
example@example.com
Permission to Update Testing

Throughout the school year, we complete ongoing updates of your child's progress. We do this by gathering information from you and other service providers your child works with including daycare, if applicable. In addition, your child's teacher and therapist(s) chart your child's progress in therapy, within the classroom and during play while at STARS preschool. At some time during every school year, we may need to update progress using standardized test materials. All progress and testing updates will be shared with you. Please give us your permission to update your child's testing as a means of measuring progress. You may receive another permission request from your school district's Committee on Preschool Education for the same testing. We require signed permission in our confidential file. Thank you for helping us to do the best job possible for your child! Yes, STARS Preschool/Liberty Post has my permission to update my child's progress by completing standardized testing during the school year.
Signed*

Clear
Date*

MonthDayYear
Date
Media Authorization:

Regulations require protecting child and family privacy. We would like your permission to use your child's photograph for educational purposes. Please indicate by circling your permission for use. Your permission may be withdrawn at any time in writing.
1. I give my permission for photographs to be used for educational purposes (E.g. developing a class "book" as part of pre-literacy activity*

YesNo
2. I give my permission for photographs to be used within the STARS Preschool. (This could be a bulletin board display, picture frame in the class or waiting area, or a class memory book).*

YesNo
3. I give my permission for my child's photograph to be used in the STARS Preschool/Liberty Post newsletter/brochure.*

yesno
4. I give my permission for my child's photograph/video to be used on the STARS Preschool/Liberty Post website.*

yesno
5.I give my permission for my child to be videotaped or photographed for use on Classroom DOJO or remote ZOOM sessions.*

yesno
6. I give my permission for my child to be videotaped for use in the STARS Preschool's activities. (Taping of school day for Open House; year-end video for moving up ceremonies, etc*

yesno
Permission for Sensory/Health/Hygiene Activities

Sensory Development: The following activities help children to learn more about their senses (sight, hearing, smell, touch, balance, movement) and to integrate that information. Good sensory development facilitates learning and helps with behavior and calming.
Please check each item or activity that you give permission for our therapists and classroom staff to do with your child:*

Sensory table items (sand, water, rice, shaving cream, finger-paint/paint)School party materials (stick-on (temporary) tattoos, cupcakes, cake, etc)Shared school snacks (food exploration- trying new foods)
If there is anything specific you would not like your child to participate in related to sensory development, please share below:
The following activities are part of natural health/hygiene education/needs:*

nail clippingbrushing teethlotionbaby wipesbrushing hairwashing facehand sanitizersoap/shampoo
Other Comments:
By signing below, I attest that my family has received and reviewed the STARS Family Handbook.
Signature of parent/guardian*

Clear
Date*

MonthDayYear
Date
By signing below, I attest that the above information is completely filled out and accurate. I grant Liberty POST STARS Preschool access to share this information among staff and use this document in reference to my child. This registration is valid for one year after the date completed.
Signature of parent/guardian completing form*

Clear
Print parent/guardian name*
Date*

MonthDayYear
Date
Should be Empty:

STARS Preschool Registration Form

By signing below, I attest that my family has received and reviewed the STARS Family Handbook.

By signing below, I attest that the above information is completely filled out and accurate. I grant Liberty POST STARS Preschool access to share this information among staff and use this document in reference to my child. This registration is valid for one year after the date completed.