Starr's Mill High School Child Development Center Enrollment Form
Child's Information
Child's Name
*
First Name
Middle Name
Last Name
Name Used at Home (Nickname)
Date of Birth
*
-
Month
-
Day
Year
Date
Home Phone
*
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Gender
*
Female
Male
Prefer not to say
Expected Start Date
*
-
Month
-
Day
Year
Date
If child does not live with both parents in one household, please select the following:
Parents are separated
Parents are divorced
Other
N/A - Child lives with both parents in one household
If the child does not live with both parents in one household, who is the child's legal guardian?
Who will the child be living with while at the center? (If the child does not live with both parents in one household and the parents share custody, please briefly describe the custody arrangement).
*
Other Persons Living in the Home
*
Name
Age
Sex
Relationship
1
2
3
4
5
6
7
8
Briefly describe your child. Tell about favorite toys, eating habits, daily routines, etc.
*
Are there any special conditions or situations that we should know about in order to provide a positive experience for your child (i.e., religious considerations, special diet concerns, etc…)
*
Is your child toilet trained?
*
Yes
No
What language does the child speak? Mark all that apply.
*
English
Chinese
French
Japanese
Korean
Spanish
Vietnamese
Other
How did you hear about our program?
Parents/Guardian Contact Information
Name
*
First Name
Last Name
Email
*
example@example.com
Relationship
*
Mother, Father, etc
Mobile Phone Number
*
Please enter a valid phone number.
Work Phone Number
*
Please enter a valid phone number.
Place of Employment
*
Address
*
Same with the child
Different Address
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Name
First Name
Last Name
Email
example@example.com
Relationship
Mother, Father, etc.
Mobile Phone Number
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Place of Employment
Address
Same with the child
Different Address
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Emergency Information
Child's Name
*
First Name
Last Name
Child's Date of Birth
*
-
Month
-
Day
Year
Date
Parent's Preferred Phone Number
*
Please enter a valid phone number.
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mother/Guardian's Name
*
First Name
Last Name
Mother/Guardian's Daytime Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mother/Guardian's Daytime Phone Number
*
Please enter a valid phone number.
Father's Name
First Name
Last Name
Father's Daytime Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Father's Daytime Phone Number
Please enter a valid phone number.
Please list a person(s) responsible for child and authorized to take the child from the center if parents are unavailable:
Emergency Contact 1
*
First Name
Last Name
Relationship
Emergency Contact 1 Phone Number
*
Please enter a valid phone number.
Emergency Contact 1 Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact 2
First Name
Last Name
Relationship
Emergency Contact 2 Phone Number
Please enter a valid phone number.
Emergency Contact 2 Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact 3
First Name
Last Name
Relationship
Emergency Contact 3 Phone Number
Please enter a valid phone number.
Emergency Contact 3 Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Does your child have any allergies or medical problems?
*
Yes
No
If you answered yes to the question above, please list/describe.
Your Child's Pediatrician
*
Pediatrician's Phone Number
*
Please enter a valid phone number.
Name of Medical Insurance Company
*
Policy Number
*
Group Number
*
Name of Policy Holder
*
First Name
Last Name
I/We desire that our child be permitted to take part in the preschool program at Starr’s Mill High School. I/We assume all risk for accident or injury to our child. I/We release the Fayette County Board of Education and Starr’s Mill High School from any liability to our child, to us, or to either of us, as parents for injuries to our child. In case of an accident, we give our permission to administer emergency treatment. I/we give permission for a Fayette County Public School Nurse to administer healthcare services as necessary.
Signature
*
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Parental Media Waiver
I/ We authorize the videotaping and/or photographing of our child for publication on both print and electronic media. We understand that our child’s likeness will appear on both print and electronic media outlets including the World Wide Web. By signing below, we agree not to hold the Fayette County School System liable for any publicity our child receives.
Signature
Tuition Statement
I understand that the full semester’s tuition for Starr’s Mill High School Child Development Center is due the first day of preschool or upon enrollment both Fall (August) and Spring (January) Semesters. This tuition is non-refundable in the case that the child does not stay enrolled the entire semester. Any child whose tuition is not paid in full will be removed from the program.
Child's Name
*
First Name
Last Name
Parent's Signature
*
Notice of Exemption Statement
I acknowledge that I have been informed that this program is not a licensed child care facility. I also understand that this program is not required to be licensed by the Georgia Department of Early Care and Learning and that this program is exempt from state licensure requirements.
Parent Signature
*
Immunization Requirement Statement
I/We understand that we are required to submit a current immunization record (GA Form 3231) or a notarized Religious Exemption Form within 30 days of the start of school. And if this form expires during my child's enrollment, I/we will provide an updated copy. If a current copy is not provided in a timely manner, my child will be removed from the program.
Signature
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