Love One Another

2031 W. Northwest Hwy Grapevine, TX 76051

First

Middle

Last

Nickname if applicable

DATE OF BIRTH

Date

HOME ADDRESS Street

City

State

Zip Code

HOME PHONE #

Divorced-Custody - Documents on file: Y N

PARENT 1GUARDIAN NAME

PARENT 2GUARDIAN NAME

HOME ADDRESS

HOME PHONE

CELL

EMAIL ADDRESS

example@example.com

EMAIL ADDRESS

example@example.com

PARENT 1 OCCUPATION

PARENT 2 OCCUPATION

If yes name of church

Other schools your child has attended

Are monthly finances a hardship?

How did you learn of our school If a specific person please enter name and address of that person

Emergency Contact (other than a parent)

Name of Emergency Contact

Relationship

Address

Phone No.

I authorize Love One Another Preschool to release my child to leave the preschool ONLY with the following persons (other than parents Children will only be released to a parent or guardian or to a person designated by the parent or guardian after verification of ID.

Name

Phone No.

Name

Phone No.

Name

Phone No.

Special Care Needs/Allergies Child's Special Care Needs (check all that apply) Environmental allergies

Limitations or restrictions on child's activities Reasonable accommodations or modifications

Injuries and hospitalizations (last 12 mos)

Adaptive equipment (include instructions below) Symptoms or indications of complications Medications prescribed for long-term use

Explain any needs selected above in Special Care Needs/Allergies: Does your child have food allergies?

Food allergy Emergency plan submitted on Date

Date

Consent for Emergency Medical Care (Texas requirement)

Childs Name

I give consent for representatives from Love One Another Preschool to secure any and all necessary emergency medical care for my child at a local medical facility.

Signature Parent or Legal Guardian

Date Signed

Website and Social Media Release

ParentGuardian name

Childs name

(Child's name) (Parent/Guardian name) grant Living Word Lutheran Church and Preschool to use photographs or video of my child for any legal use, included, but not limited to: publicity, copyright purposes, illustration, advertising, and web content.

ParentGuardian Name Printed

ParentGuardian Signature

CHILDS HEALTH RECORD A copy of your childs immunizations and current physical will be needed General state of health

Doctors name

Phone number

(Please attach a copy of immunizations. This Are your child's immunizations up to date? should include the signature of nurse or doctor who administered medications. If not, please attach medical exemption signed by doctor or notarized waiver

Does your child have any known allergies

Are you concerned that your child may be prone to any type of allergies? Describe:

Are you concerned that your child may be prone to any type of allergies

Describe

Does your child have any medical conditions which I should be made aware of

Has your child had the following common childhood illnesses? Constipation ConvulsionsBronchitis DiarrheaChicken Pox Fainting SpellsDiabetes Frequent ColdsHeart Disease Frequent Ear InfectionsHepatitis Frequent Sore ThroatsImpetigo Measles RingwormMumps Skin Rash German Measles Soiling Scarlet Fever Stomach Upsets Urinary ProblemTuberculosis Whooping Cough

Does your child have any speech hearing or visual problems

Would there be any restrictions to play or activities

Parent Signature I verify that all the above information in this application is true and complete to the best of my knowledge.

Parent Signature

Date

Parent Name Printed

Love One Another

LOVE ONE ANOTHER PRESCHOOL APPLICATION 25-26

CHILD'S NAME: