Preschool Application Form 25-26
The Growing Place 1221 Quarrier Street Charleston, WV 25301
Full Name of Child
*
First Name
Middle Name
Last Name
Gender
*
Boy
Girl
Date of birth
*
-
Month
-
Day
Year
Date
Please Choose Desired Hours of Care
*
Preschool Only 9:00 AM-12:00 PM
Preschool with Aftercare Level I 9:00 AM-3:00 PM
Preschool with Aftercare Level II 9:00-5:30 PM
Wednesday Care (Only Applies to KCS Pre-k students)
Please Choose Days of Attendance
*
Monday
Tuesday
Wednesday
Thursday
Friday
Will you Be Utilizing Early Drop-off?
*
Yes 6:15-7:00 AM ($10/day)
Yes 7:00-7:45 AM ($5/day)
Yes 8:00 AM ($2.50/day)
No
Parent or Guardian 1
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Authorized Pickup?
*
Yes
No
Parent or Guardian 2
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Authorized Pickup?
*
Yes
No
Is there a court order affecting the care of the child?
*
Yes
No
Please specify
*
We will need a certified copy.
Does your child have any allergies?
*
Yes
No
If yes, please list.
*
Does your child have any dietary needs or restrictions?
*
Yes
No
If yes, please list.
*
Documentation from Physician Required
Does your child take medication that will need to be administered by us?
*
Yes
No
If yes, please list.
*
Prescription from Physician Required
Child's Pediatrician
*
Name of Practice
Name of Physician
Location
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Hospital in Case of Emergency
*
Name of Hospital
Health Inurance (Attach Proof of Coverage)
*
Provider
Group ID
Signature of Parent or Gaurdian
*
Date
*
/
Month
/
Day
Year
Date
Back
Next
Consent Form
Child's Name
*
First Name
Last Name
I authorize The Growing Place to obtain emergency medical care and medical transportation for my child.
*
Yes
No
I consent to having sunscreen and/or insect repellent (that I provide) applied to my child as often as needed.
*
Yes
No
Consent to Photograph
*
Procare (to registered parent only)
Procare and in-center use
Procare, center, and advertising use (website, social media, newsletters)
I do NOT give consent
Signature
*
Date
*
-
Month
-
Day
Year
Date
Back
Next
Emergency Contact Form
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Authorized Pickup?
*
Yes
No
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Authorized Pickup?
*
Yes
No
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Authorized Pickup?
*
Yes
No
Signature
*
Date
*
-
Month
-
Day
Year
Date
Vaccine Records, Well-child Visit, Birth Certificate, Insurance Card, Dental Visit
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These forms are required before your child can attend. You may also drop the forms off at the office. Thank You!
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